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Vincent Rossi, Anthony Asher, David Peters, Scott L. Zuckerman, Mark Smith, Martin Henegar, Hunter Dyer, Domagoj Coric, Deborah Pfortmiller, Tim Adamson and Matthew McGirt

OBJECTIVE

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 > 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.

METHODS

A retrospective analysis of 119 consecutive patients > 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.

RESULTS

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%.

CONCLUSIONS

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.

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Richard P. Menger, Bharat Guthikonda, Christopher M. Storey, Anil Nanda, Matthew McGirt and Anthony Asher

Neurosurgeons provide direct individualized care to patients. However, the majority of regulations affecting the relative value of patient-related care are drafted by policy experts whose focus is typically system- and population-based. A central, prospectively gathered, national outcomes-related database serves as neurosurgery’s best opportunity to bring patient-centered outcomes to the policy arena.

In this study the authors analyze the impact of the Affordable Care Act (ACA) on the determination of quality and value in neurosurgery care through the scope, language, and terminology of policy experts. The methods by which the ACA came into law and the subsequent quality implications this legislation has for neurosurgery will be discussed. The necessity of neurosurgical patient-oriented clinical registries will be discussed in the context of imminent and dramatic reforms related to medical cost containment.

In the policy debate moving forward, the strength of neurosurgery’s argument will rest on data, unity, and proactiveness. The National Neurosurgery Quality and Outcomes Database (N2QOD) allows neurosurgeons to generate objective data on specialty-specific value and quality determinations; it allows neurosurgeons to bring the patient-physician interaction to the policy debate.