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Study Design Cross-sectional study. Objective To assess the current practices of spine surgeons performing ambulatory surgery in the United States. Methods An electronic survey was distributed to members of the International Society for the Advancement of Spine Surgery. Data were initially examined in a univariate manner; variables with a p value < 0.25 were entered into a multiple logistic regression model. All statistical analyses were performed using the SAS System software Version 9.2 (SAS Institute, Inc., Cary, North Carolina, United States). Results Overall, 84.2% of respondents performed some manner of ambulatory spine surgery, and 49.1% were investors in an ambulatory surgery center. Surgeon investors in ambulatory surgery centers were more likely to perform procedures of increased complexity than noninvestors, though limited data precluded a statistical correlation. Surgeons in private practice were more likely to perform ambulatory surgery (94.3%; p = 0.0176), and nonacademic surgeons were both more likely to invest in ambulatory surgery centers (p = 0.0024) and perform surgery at least part of the time in a surgery center (p = 0.0039). Conclusions Though the numbers were too few to calculate statistical significance, there was a trend toward the performance of high-risk procedures on an ambulatory basis being undertaken by those with investment status in an ambulatory center. It is possible that this plays a role in the decision to perform these procedures in this setting versus that of a hospital, where a patient may have better access to care should a complication arise requiring emergent assessment and treatment by a physician. This decision should divest itself of financial incentives and focus entirely on patient safety.
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Ambulatory Spine Surgery: A Survey Study
Evan O. Baird1Sasha C. Brietzke2Alan D. Weinberg2Steven J. McAnany1Sheeraz A. Qureshi1
Samuel K. Cho1Andrew C. Hecht1
1Department of Orthopaedics, Mount Sinai School of Medicine,
New York, New York, United States
2Department of Health Evidence and Policy, Mount Sinai School of
Medicine, New York, New York, United States
Global Spine J 2014;4:157160.
Address for correspondence Andrew C. Hecht, MD, 5 East 98th Street,
Box 1188, New York, NY 10029, United States
(e-mail: andrew.hecht@mountsinai.org).
Introduction
The performance of ambulatory surgical procedures is on the
rise across all surgical elds, ranging from thyroid surgery1to
cholecystectomy.2The eld of orthopedic surgery has fol-
lowed a similar path, with an ever-increasing practice trend
of outpatient knee and shoulder arthroscopy3,4 and more
recently lumbar and cervical spine surgery.58Given these
trends, we sought to assess the outpatient spine surgery
environment and report the types of cases being performed
by those surgeons who perform spine surgery in this setting.
We conducted a survey of spine surgeon members of the
International Society for the Advancement of Spine Surgery
(ISASS) regarding their experience with ambulatory spine
surgery. In so doing, we hoped to characterize the current
practice of spine surgeon members of this society, including
Keywords
spine surgery
ambulatory surgery
complications
Abstract Study Design Cross-sectional study.
Objective To assess the current practices of spine surgeons performing ambulatory
surgery in the United States.
Methods An electronic survey was distributed to members of the International
Society for the Advancement of Spine Surgery. Data were initially examined in a
univariate manner; variables with a pvalue <0.25 were entered into a multiple logistic
regression model. All statistical analyses were performed using the SAS System software
Version 9.2 (SAS Institute, Inc., Cary, North Carolina, United States).
Results Overall, 84.2% of respondents performed some manner of ambulatory spine
surgery, and 49.1% were investors in an ambulatory surgery center. Surgeon investors in
ambulatory surgery centers were more likely to perform procedures of increased
complexity than noninvestors, though limited data precluded a statistical correlation.
Surgeons in private practice were more likely to perform ambulatory surgery (94.3%;
p¼0.0176), and nonacademic surgeons were both more likely to invest in ambulatory
surgery centers (p¼0.0024) and perform surgery at least part of the time in a surgery
center (p¼0.0039).
Conclusions Though the numbers were too few to calculate statistical signicance,
there was a trend toward the performance of high-risk procedures on an ambulatory
basis being undertaken by those with investment status in an ambulatory center. It is
possible that this plays a role in the decision to perform these procedures in this setting
versus that of a hospital, where a patient may have better access to care should a
complication arise requiring emergent assessment and treatment by a physician. This
decision should divest itself of nancial incentives and focus entirely on patient safety.
received
March 24, 2014
accepted
April 29, 2014
published online
June 9, 2014
© 2014 Georg Thieme Verlag KG
Stuttgart · New York
DOI http://dx.doi.org/
10.1055/s-0034-1378142.
ISSN 2192-5682.
Global Spine Journal Original Article 157
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the characteristics of respondents performing ambulatory
surgery, the surgical procedures being performed, the setting
of ambulatory surgery as well as the associated self-reported
complications encountered during the performance of am-
bulatory surgery.
Materials and Methods
The electronic survey consisted of 25 questions and was
distributed to members of the ISASS over a 3-month period
from July through September 2012. After this time, the
response Web link was disabled. By providing each respon-
dent with a unique link, we avoided multiple responses from
a single participant.
For the analysis of factors potentially associated with
ambulatory spine surgery, data were rst examined in a
univariate manner using the Student ttest for continuous
variables and Fisher exact test for discrete data. For the
multivariate analysis, variables with a pvalue <0.25 were
entered into a multiple logistic regression model, because we
interpreted these variables as independent factors associated
with the event or outcome of interest, over and above (adjusted
for) other potential factors included in the equation. The
logistic equation generates pvalues and odds ratios for each
explanatory variables association with the outcome of inter-
est. For all statistical analysis, data were analyzed using the SAS
System software Version 9.2 (SAS Institute, Inc., Cary, North
Carolina, United States). The pvalues were not adjusted for
multiple testing and a potential ination of the type I error.
Results
The number of responses from U.S.-based surgeons totaled
57. We found that 75.4% of respondents were trained in
orthopedic surgery, with the remainder having been trained
in neurosurgery. In addition, 87.7% of surgeon respondents
were spine fellowship trained; 61.4% were in private practice,
31.6% in academic practice, and 7.0% in a hospital employ-
ment position. The majority (54.4%) classify themselves as
practicing in an urban environment, with 42.1% in a suburban
environment and 3.5% in a rural area. 84.2% of respondents
performed some manner of ambulatory spine surgery,
whether in a hospital or ambulatory surgery center setting.
Of the responding surgeons, 49.1% invest in an ambulatory
surgery center; of those who perform surgery in such a
center, 81.5% are investors; and in those performing ambula-
tory surgery in a hospital setting only, 21.1% invest in a
surgery center (Table 1). Common procedures were single-
(performed by 70.8% of surgeons) or multiple-level (41.7%)
lumbar microdiskectomy, single- (62.5%) or multiple-level
(33.3%) lumbar laminectomy, and one- (54.2%) and two-level
(39.6%) anterior cervical diskectomy and fusion. Surgeon
investors in ambulatory surgery centers were more likely to
perform procedures of increased complexity (i.e., multilevel
anterior cervical fusion procedures) than noninvestors (21.4%
versus 3.4%); in other words, of those performing such
procedures, 85.7% were investors. The numbers in this analy-
sis were too small to perform statistical analysis.
Surgeons in private practice were more likely to perform
ambulatory surgery (94.3%; p¼0.0176), and nonacademic
surgeons (i.e., those in private practice or community hospi-
tal-based) were more likely to invest in ambulatory surgery
centers (67.6%; p¼0.0024) and perform surger y at least part
of the time in a surgery center (p¼0.0039; Table 2). In the
univariate analysis, status as an orthopedic surgeon (versus a
neurosurgeon) did not correlate with performance of outpa-
tient surgery (p¼0.5084), with investment in an ambulatory
surgery center (p¼0.3084), or with the location of the
ambulatory surgery (p¼0.9798; Table 3). Of note, taken
together as a group, being in practice for 20 years or less did
correlate with the likelihood of investing in a surgery center
(p¼0.0333; Table 2). Location of performance of ambula-
tory surgery did not appear to affect whether the primary
surgeon co-operated with another surgeon. Among those
performing ambulatory surgery at least sometimes in ambu-
latory surgery centers, 48.3% reported the availability of
23-hour observation should the patient require it; the
remainder indicated that transfer to another facility would
be necessary for further care. In addition, 10.3% of surgeons
reported a complication that could not be addressed in the
ambulatory center environment; 92% noted that in the event
of such a complication, there was a protocol in place designed
to manage such episodes.
Discussion
Cervical and lumbar spine surgery is being performed
more commonly on an ambulatory basis,58possibly
Table 1 Characteristics of survey respondents (n¼57)
Characteristic n
Fellowship training 50 (87.7%)
Orthopedic surgeon 43 (75.4%)
Neurosurgeon 14 (24.6%)
Private practice 35 (61.4%)
Academic practice 18 (31.6%)
Hospital employment 4 (7.0%)
Urban environment 31 (54.4%)
Suburban environment 24 (42.1%)
Rural environment 2 (3.5%)
05 y in practice 8 (14.0%)
610 y in practice 6 (10.5%)
1120 y in practice 20 (35.1%)
>20 y in practice 23 (40.4%)
Perform ambulatory surgery 48 (84.2%)
Hospital setting 19 (39.6%)
Ambulatory surgery center 10 (20.8%)
Both 19 (39.6%)
Investment in ambulatory surgery center 28 (49.1%)
Global Spine Journal Vol. 4 No. 3/2014
Ambulatory Spine Surgery Baird et al.158
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driven by the development of minimally invasive techni-
ques, which has been shown to minimize immediate post-
operative pain and accelerate postoperative recovery.911
Anotherfactormaybesurgeonnancial incentive
when performing the surgery in a physician-owned ambu-
latory surgery center.12 This survey was able to provide an
overview of the characteristics of surgeons performing
surgery on an outpatient basis, the location for the perfor-
mance of the surgeries, and the types of cases being
performed.
Based on the data gathered, practicing as a member of a
nonacademic practice correlated with the performance of
ambulatory surgery, the utilization of an ambulatory surgery
center, and investment in an ambulatory surgery center.
Likewise, being in practice for 20 or fewer years and being
a member of a nonacademic practice correlated with invest-
ment in an ambulatory surgery center.
Finally, as noted above, though the numbers were too
few to calculate statistical signicance, there was a trend
toward performance of both surgery in ambulatory surgery
centers and procedures associated with increased risk
(i.e., multilevel anterior cervical fusion procedures) on an
ambulatory basis being undertaken largely by investors in
an ambulatory center. Given the nancial incentives in-
volved in an ambulatory surgery center, it is possible that
this plays a role in the decision to perform these procedures
in this setting versus that of a hospital, where a patient may
have better access to care should a postoperative compli-
cation arise requiring emergent assessment and treatment
by a physician. Of some concern is that 8% of surgeons
performing spinal procedures did not have a mechanism for
dealing with complications that could not be managed in
the ambulatory surgery center. Last, 10.3% of surgeons
identied complications that could not be handled in their
center.
Limitations to our study include those inherent to survey
studies (sampling error, nonresponse error, coverage error)
and a relatively small number of respondents. Ideally, a study
such as ours would include survey distribution to a wider
range of spine surgeon professional societies, providing a more
thorough and accurate analysis of the patterns of performance
of spine surgery in the ambulatory setting. The authors
undertook this study not with the intention of criticizing the
use of ambulatory surgery centers for spine surgery as a whole,
but with the hope that this study will serve to open discussion
on the types of procedures that can be safely performed in an
ambulatory surgery center. This discussion should divest itself
of nancial incentives and focus entirely on patient safety and
mechanisms to deal with complications that cannot be man-
aged in ambulatory centers.
Disclosures
The authors did not receive grants or outside funding in
support of their research or for preparation of this manu-
script. This manuscript does not require approval from our
Table 2 Multivariate logistic regression analyses
pOR (95% CI)
Model
Private practice setting versus performance of ambulatory
surgery
0.0176
a
7.700 (1.42741.556)
Nonacademic practice setting versus performance of ambulatory
surgery at least part time in surgery center
0.0039
a
11.459 (2.18760.048)
Nonacademic practice setting versus investment in surgery
center
0.0024
a
9.854 (2.24543.241)
20 y in practice versus investment in surgery center 0.0333
a
4.050 (1.11714.675)
Abbreviations: CI, condence interval; OR, odds ratio.
a
p<0.05 (statistically signicant).
Table 3 Univariate logistic regression analyses: surgeon characteristics versus likelihood of performing ambulatory surger y, location
of ambulatory surgery, and investment in an ambulatory surgery center
Variable Outcome Perform ambulatory
surgery
Ambulatory surgery at least
part time in surgery center
Invest in surgery center
Orthopedic specialist 0.5084 0.9798 0.3084
Nonacademic practice setting 0.0219
a
0.0039
a
0.0012
a
Urban practice location 0.4247 0.0466
a,b
0.2205
20 y in practice 0.3174 0.0467
a
0.0120
a
a
p<0.05 (statistically signicant).
b
Based on measurement of suburban rather than urban location.
Global Spine Journal Vol. 4 No. 3/2014
Ambulatory Spine Surgery Baird et al. 159
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institutions Institutional Review Board. This manuscript
does not describe the use of medical device(s)/drug(s).
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... In a survey study of orthopedicand neurosurgery-trained spine surgeons, 84.2% performed some degree of ambulatory spine surgery; 94.3% of surgeons in private practice performed ambulatory surgery. Among these surgeons, 39.6% performed ambulatory surgery in the hospital setting, 20.8% utilized an ASC, and 39.6% used both [32] . In a study of the New York Statewide Planning and Research Cooperative System, 96 surgeons performed outpatient ACDF or cervical disc arthroplasty in 2010, compared to 376 surgeons in 2018 [33] . ...
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Background There is growing interest in transitioning various surgical procedures to the outpatient care setting. However, for Medicare patients, the site of service for surgical procedures is influenced by regulations within the Inpatient and Outpatient Prospective Payment Systems. The purpose of this study is to quantify changes in utilization of outpatient spine surgery within the Medicare population, as well as to determine changes in outpatient volume after removal of a procedure from the “inpatient-only” list. Methods This is a cross-sectional study of Medicare billing database information for selected spine procedures included in the Medicare Physician/Supplier Procedure Summary (PSPS) public use files from 2010–2021. These files include aggregated data from Medicare Part B fee-for-service claims, published yearly. Procedures from Healthcare Common Procedural Coding System (HCPCS) code ranges 22010–22899 and 62380–63103 were selected for analysis, limited to surgical services delivered in the inpatient, hospital outpatient department (HOPD), and ambulatory surgical center (ASC) settings. For each HCPCS code included, estimates of the total number of services and corresponding changes in volume were calculated. Results Within the range of codes included in the study, the total number of outpatient spine procedures rose approximately 193% from 2010 to 2021, with compound annual growth rate (CAGR) for outpatient procedures per year of 9.9% for HOPDs and 15.7% for ASCs (-2.2% for inpatient procedures). Within this period, the ASC list grew from 12 procedures to 58 procedures. In 2021, the highest volume ASC procedure was HCPCS 63047, at approximately 4970 procedures. Conclusions This study demonstrates a trend of increasing utilization of HOPDs and ASCs for spine procedures among Medicare beneficiaries from 2010 to 2021. Though HOPDs are currently more widely utilized, the ongoing additions of spine procedures to the ASC covered procedures list may shift this balance.
... Two studies looked specifically at the results of 1-level ACDF performed in ASC [ Tables 1, 2]. [4,5] In Table 1]. [5] [3] ey additionally found a "trend" for invested spine surgeons to perform increasingly complicated operations in these facilities. Further, they were concerned that at least some of these ASC procedures should still be done in hospitals; "...where a patient may have better access to emergency care. ...
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Background Can anterior cervical diskectomy/fusion (ACDF) be safely performed in ambulatory surgical centers (ASC’s: i.e. discharges 4-7.5 hr. postoperatively) that meet the following stringent “exclusion criteria”; elevated Body Mass Index (BMI), major comorbidities, age > 65, American Society of Anesthesiology (ASA) scores > II, and largely multilevel ACDF. Materials Presently, most ACDF are still being performed in hospital-based outpatient surgical centers (HBSC: utilizing 23-hour stays), or as inpatients. Results Notably, unreliable disparate study designs involving very different patient populations resulted in nearly comparable, but implausible outcomes for 1-level vs. multilevel ACDF series performed in ASC. A summary of these outcome data included the following rates of; i.e. postoperative hospital transfers (0-6%), 30-day (up to 2.2%), and up to 90 day (2.2%) emergency department (ED) visits, readmissions, and reoperations. Conclusion Nevertheless, it is just common sense that “less should be less”, that 1-level ACDF should involve less risk compared with multilevel ACDF procedures performed in ASC.
... 29 While some spine procedures are steadily shifting out of the hospital setting, one of the most prevalent and costly proceduresthe lumbar fusion-remains largely an inpatient event. [30][31][32][33][34] Some studies have reported a gradual increase in the prevalence of outpatient or ambulatory lumbar fusions in recent years; however, this trend has been halting at best. 16 One possible explanation for this is that surgeons and medical centers question the safety of outpatient lumbar fusion, fearing that the lack of inpatient observation after surgery could increase the risk of complications. ...
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Elective hemithyroidectomy is a common operation with a low complication rate. The aim of this study was to conduct an audit on the safety and efficacy of ambulatory hemithyroidectomy in carefully-selected patients. This is a cohort study of 114 patients who were scheduled to have either ambulatory (50 patients) or inpatient (64 patients) hemithyroidectomy over a two-year period. Selection for day case surgery was based on pre-established criteria and patient preference. Preoperative patient characteristics, indications for surgery, operative characteristics, histological diagnoses and surgical complications are compared. Of the 50 patients selected for day case surgery, 45 (90 percent) were discharged on the day of surgery. The complication rates of the two groups were similar. Two patients required admission for wound complications and the other three were admitted for non-medical reasons. The overall complication rate was low. There were no differences in the rate of complications between ambulatory and inpatient hemithyroidectomies. Ambulatory hemithyroidectomy can be performed safely for a select group of patients in the setting of appropriate facility and management protocol.
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Prospective observational cohort study. Comparison of clinical and radiological outcomes of single-level open versus minimally invasive (MIS) transforaminal lumbar interbody fusion (TLIF) at 6 months and 2-year follow-up. There is recognition that more data are required to ascertain the benefits and risks of MIS vis-a-vis open TLIF. This study aims to report on one of the largest currently available series comparing the clinical and radiological outcomes of the two procedures with a minimum follow-up of 2 years. From January 2002 to March 2008, 144 single-level open and MIS TLIF were performed at our centre, with 72 patients in each group. Clinical outcomes were based on patient-reported outcome measures recorded at the Orthopaedic Diagnostic Centre by independent assessors before surgery, at 6 months and 2 years post-operatively. These were visual analogue scores (VAS) for back and leg pain, Oswestry disability index (ODI), short form-36 (SF-36), North American Spine Society (NASS) scores for neurogenic symptoms, returning to full function, and patient rating of the overall result of surgery. Radiological fusion based on the Bridwell grading system was also assessed at 6 months and 2 years post-operatively by independent assessors. In terms of demographics, the two groups were similar in terms of patient sample size, age, gender, body mass index (BMI), spinal levels operated, and all the clinical outcome measures (p > 0.05). Perioperative analysis revealed that MIS cases have comparable operative duration (open: 181.8 min, MIS: 166.4 min, p > 0.05), longer fluoroscopic time (open: 17.6 s, MIS: 49.0 s, p < 0.05), less intra-operative blood loss (open: 447.4 ml, MIS: 50.6 ml, p < 0.05) and no post-operative drainage (open: 528.9 ml, MIS: 0 ml, p < 0.05). MIS patients needed less morphine (open: 33.5 mg, MIS: 3.4 mg, p < 0.05) and were able to ambulate (open: 3.4 days, MIS: 1.2 days, p < 0.05) and be discharged from hospital earlier (open: 6.8 days, MIS: 3.2 days, p < 0.05). At 6 months, clinical outcome analysis showed both groups improving significantly (>50.0 %) and similarly in terms of VAS, ODI, SF-36, return to full function and patient rating (p > 0.05). Radiological analysis showed similar grade 1 fusion rates (open: 52.2 %, MIS: 59.4 %, p > 0.05) with small percentage of patients developing asymptomatic cage migration (open: 8.7 %, MIS: 5.8 %, p > 0.05). One major complication (open: myocardial infarction, MIS: screw malpositioning requiring subsequent revision) and two minor complications in each group (open: pneumonia and post-surgery anemia, MIS: incidental durotomy and pneumonia) were noted. At 2 years, continued improvements were observed in both groups as compared to the preoperative state (p > 0.05), with 50.8 % of open and 58 % of MIS TLIF patients returning to full function (p > 0.05). Almost all patients have Grade 1 fusion (open: 98.5 %, MIS: 97.0 %, p > 0.05) with minimal new cage migration (open: 1.4 %, MIS: 0 %, p > 0.05). MIS TLIF is a safe option for lumbar fusion, and when compared to open TLIF, has similar operative duration, good clinical and radiological outcomes, with additional significant benefits of less perioperative blood loss and pain, earlier rehabilitation, and a shorter hospitalization.
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This study was proposed to investigate the changes in the utilization of knee arthroscopy in an ambulatory setting over the past decade in the United States as well as its implications. The National Survey of Ambulatory Surgery, last carried out in 1996, was conducted again in 2006 by the Centers for Disease Control and Prevention. We analyzed the cases with procedure coding indicative of knee arthroscopy or anterior cruciate ligament reconstruction. To produce estimates for all arthroscopic procedures on the knee in an ambulatory setting in the United States for each year, we performed a design-based statistical analysis. The number of arthroscopic procedures on the knee increased 49% between 1996 and 2006. While the number of arthroscopic procedures for knee injury had dramatically increased, arthroscopic procedures for knee osteoarthritis had decreased. In 1996, knee arthroscopies performed in freestanding ambulatory surgery centers comprised only 15% of all orthopaedic procedures, but the proportion increased to 51% in 2006. There was a large increase in knee arthroscopy among middle-aged patients regardless of sex. In 2006, >99% of arthroscopic procedures on the knee were in an outpatient setting. Approximately 984,607 arthroscopic procedures on the knee (95% confidence interval, 895,999 to 1,073,215) were performed in an outpatient setting in 2006. Among those, 127,446 procedures (95% confidence interval, 95,124 to 159,768) were for anterior cruciate ligament reconstruction. Nearly 500,000 arthroscopic procedures were performed for medial or lateral meniscal tears. This study revealed that the knee arthroscopy rate in the United States was more than twofold higher than in England or Ontario, Canada, in 2006. Our study found that nearly half of the knee arthroscopic procedures were performed for meniscal tears. Meniscal damage, detected by magnetic resonance imaging, is commonly assumed to be the source of pain and symptoms. Further study is imperative to better define the symptoms, physical findings, and radiographic findings that are predictive of successful arthroscopic treatment.
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Retrospective cohort comparison between minimally invasive (MIS) and open transforaminal lumbar interbody fusion (TLIF). To assess 2 earlier unstudied endpoints (duration of narcotic use and return to work) and long-term pain, disability, and quality of life (QOL) for MIS-TLIF versus open-TLIF. MIS-TLIF for lumbar spondylolithesis theoretically allows for surgical treatment of back and leg pain while minimizing blood loss and tissue injury. Although earlier studies have shown shorter hospital stay and equivocal 6 and 24 month outcomes with MIS-TLIF versus open-TLIF, the effect of MIS techniques on postoperative narcotic use and return to work are poorly understood. Thirty patients undergoing MIS-TLIF (n = 15) or open-TLIF (n = 15) for grade I degenerative spondylolithesis-associated back and leg pain were enrolled. Two-year outcomes were assessed through phone interview and it included pain [visual analog scale (VAS)], low-back disability (Oswestry disability index), EuroQol-5D, occupational disability, and narcotic use. MIS-TLIF versus open-TLIF cohorts were similar at baseline. Median [interquartile range (IQR)] length of hospitalization after surgery was significantly less for MIS-TLIF versus open-TLIF [3 (3 to 3) vs 5.5 (4 to 6) d], P = 0.001. MIS-TLIF versus open-TLIF patients showed similar 2-year improvement in VAS for back pain, VAS for leg pain, Oswestry disability index, and EuroQol-5D scores. Overall, median (IQR) length of postoperative narcotic use was 3.0 (1.4 to 4.6) weeks and significantly shorter for MIS-TLIF versus open-TLIF patients [2.0 (1.0 to 3.0) vs 4.0 (1.4 to 4.6) wk, P = 0.008]. Overall, median (IQR) time to return to work was 13.9 (2.2 to 25.5) weeks and significantly shorter for MIS-TLIF versus open-TLIF patients [8.5 (4.4 to 21.4) vs 17.1 (1.8 to 35.9) wk, P = 0.02]. Both MIS-TLIF and open-TLIF provide long-term improvement in pain, disability, and EuroQol-5D in patients with back and leg pain from grade I degenerative spondylolithesis. However, MIS-TLIF may allow for shortened hospital stays, reduced postoperative narcotic use, and accelerated return to work, reducing both direct medical costs and indirect costs of lost work productivity associated with TLIF procedures.
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Many physicians confronting declining reimbursement from insurers have invested in ambulatory surgery centers, where they perform outpatient surgical and diagnostic procedures. An ownership stake entitles physicians to a share of the facility's profits from self-referrals. This arrangement can create a potential conflict of interest between physicians' financial incentives and patients' clinical needs. Our analysis of Florida data for five common procedures revealed a significant association between physician-ownership and higher surgical volume. Possible remedies include revising federal law to require disclosure of investment arrangements; reducing facility payments to dilute ownership incentives; and reforms (such as accountable care organizations) that discourage an excessive rate of procedures.
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Retrospective cohort. To describe population-based trends and variations in surgery for degenerative changes of the cervical spine among Medicare beneficiaries, 1992 to 2005. Degenerative changes of the cervical spine are seen radiographically in over half of the population aged 55 years or greater, and rates of cervical spine surgery have increased over time. Prior studies examined anterior cervical discectomy and fusion procedures in the general population up to 1999, and showed regional variations in care, with the highest rates in the South. The purpose of this study is to explore population-based trends and variations in surgery for degenerative changes of the cervical spine in the elderly. From 1992 to 2005, hospital admissions associated with surgery for degenerative changes of the cervical spine were selected from Medicare Part A using ICD9 CM codes. We excluded beneficiaries under 65 years of age, in a capitated health plan, or enrolled for Social Security Disability Income. Diagnosis and type of surgery were defined using ICD9 CM codes. Rates were directly adjusted to age, sex, and race of 2005 Medicare beneficiaries. Of 156,820 qualifying admissions, 52% were men, 88% were white, and 41% were aged 65 to 69 years. The most common primary diagnosis and procedure were cervical spondylosis with myelopathy (36%) and fusion (70%); of the fusions, 58% were anterior. Rates of cervical fusions rose from 1992 to 2005 even after adjustment for age, sex, and race (14.7 to 45 cervical fusions/100,000 beneficiaries). Rates of cervical fusions varied by geographic location, with the highest rates in the Northwest and South Central regions. In 2005, the highest rate of cervical fusions was 140/100,000 beneficiaries in Idaho, compared with 4/100,000 beneficiaries in Washington, DC. In the elderly, adjusted rates of cervical spine fusions rose 206% from 1992 to 2005. Marked geographic variation was noted. Future studies should evaluate the efficacy and complications associated with these procedures in the elderly, and better define surgical indications and patient outcome.
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Arthroscopic shoulder reconstructive surgery has been handled in many different ways. However, there currently is significant evidence and experience to show that doing this surgery on an outpatient basis is not only cost-effective and efficient, but safe and beneficial to patients. New arthroscopic surgical techniques and the use of regional interscalene anesthesia have been shown to provide effective and comfortable intraoperative conditions, while allowing for prolonged analgesia and quicker recovery with minimal side effects. The authors will discuss their approach to surgery, anesthesia, and recovery for outpatient shoulder reconstruction.
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Sequential cross-sectional study. To quantify patterns of outpatient lumbar spine surgery. Outpatient lumbar spine surgery patterns are undocumented. We used CPT-4 and ICD-9-CM diagnosis/procedure codes to identify lumbar spine operations in 20+ year olds. We combined sample volume estimates from the National Hospital Discharge Survey (NHDS), the National Survey of Ambulatory Surgery (NSAS), and the Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS) with complete case counts from HCUP's State Inpatient Databases (SIDs) and State Ambulatory Surgery Databases (SASDs) for four geographically diverse states. We excluded pregnant patients and those with vertebral fractures, cancer, trauma, or infection. We calculated age- and sex-adjusted rates. Ambulatory cases comprised 4% to 13% of procedures performed from 1994 to 1996 (NHDS/NSAS data), versus 9% to 17% for 1997 to 2000 (SID/SASD data). Discectomies comprised 70% to 90% of outpatient cases. Conversely, proportions of discectomies performed on outpatients rose from 4% in 1994 to 26% in 2000. Outpatient fusions and laminectomies were uncommon. NIS data indicate that nationwide inpatient surgery rates were stable (159 cases/100,000 in 1994 vs. 162/100,000 in 2000). However, combined data from all sources suggest that inpatient and outpatient rates rose from 164 cases/100,000 in 1994 to 201/100,000 in 2000. While inpatient lumbar surgery rates remained relatively stable for 1994 to 2000, outpatient surgery increased over time.