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The impact of the reserve military neurosurgeon: practice, community, and service

Richard Menger, Benjamin F. Mundell, J. Will Robbins, Peter Letarte, Randy Bell, and in conjunction with Council of State Neurosurgical Societies and AANS/CNS Joint Committee of Military Neurosurgeons

OBJECTIVE

Papers from 2002 to 2017 have highlighted consistent unique socioeconomic challenges and opportunities facing military neurosurgeons. Here, the authors focus on the reserve military neurosurgeon who carries the dual mission of both civilian and military responsibilities.

METHODS

Survey solicitation of current active duty and reserve military neurosurgeons was performed in conjunction with the AANS/CNS Joint Committee of Military Neurosurgeons and the Council of State Neurosurgical Societies. Demographic, qualitative, and quantitative data points were compared between reserve and active duty military neurosurgeons. Civilian neurosurgical provider data were taken from the 2016 NERVES (Neurosurgery Executives Resource Value and Education Society) Socio-Economic Survey. Economic modeling was done to forecast the impact of deployment or mobilization on the reserve neurosurgeon, neurosurgery practice, and the community.

RESULTS

Seventy-five percent (12/16) of current reserve neurosurgeons reported that they are satisfied with their military service. Reserve neurosurgeons make significant contributions to the military’s neurosurgical capabilities, with 75% (12/16) having been deployed during their career. No statistically significant demographic differences were found between those serving on active duty and those in the reserve service. However, those who served in the reserves were more likely to desire opportunities for improvement in the military workflow requirements compared with their active duty counterparts (p = 0.04); 92.9% (13/14) of current reserve neurosurgeons desired more flexible military drill programs specific to the needs of practicing physicians. The risk of reserve deployment is also borne by the practices, hospitals, and communities in which the neurosurgeon serves in civilian practice. This can result in fewer new patient encounters, decreased collections, decreased work relative value unit generation, increased operating costs per neurosurgeon, and intangible limitations on practice development. However, through modeling, the authors have illustrated that reserve physicians joining a larger group practice can significantly mitigate this risk. What remains astonishing is that 91.7% of those reserve neurosurgeons who were deployed noted the experience to be rewarding despite seeing a 20% reduction in income, on average, during the fiscal year of a 6-month deployment.

CONCLUSIONS

Reserve neurosurgeons are satisfied with their military service while making substantial contributions to the military’s neurosurgical capabilities, with the overwhelming majority of current military reservists having been deployed or mobilized during their reserve commitments. Through the authors’ modeling, the impact of deployment on the military neurosurgeon, neurosurgeon’s practice, and the local community can be significantly mitigated by a larger practice environment.

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Does patient selection account for the perceived cost savings in outpatient spine surgery? A meta-analysis of current evidence and analysis from an administrative database

Presented at the 2018 AANS/CNS Joint Section on Disorders of the Spine and Peripheral Nerves

Benjamin F. Mundell, Marcus J. Gates, Panagiotis Kerezoudis, Mohammed Ali Alvi, Brett A. Freedman, Ahmad Nassr, Samuel F. Hohmann, and Mohamad Bydon

OBJECTIVE

From 1994 to 2006 outpatient spinal surgery increased 5-fold. The perceived cost savings with outcomes comparable to or better than those achieved with inpatient admission for the same procedures are desirable in an era where health expenditures are scrutinized. The increase in outpatient spine surgery is also driven by the proliferation of ambulatory surgery centers. In this study, the authors hypothesized that the total savings in outpatient spine surgery is largely driven by patient selection and biases toward healthier patients.

METHODS

A meta-analysis assessed patient selection factors and outcomes associated with outpatient spine procedures. Pooled odds ratios and mean differences were calculated using a Bayesian random-effects model. The authors extended this analysis in a novel way by using the results of the meta-analysis to examine cost data from an administrative database of academically affiliated hospitals. A Bayesian approach with priors informed by the meta-analysis was used to compare costs for inpatient and outpatient performance of anterior cervical discectomy and fusion (ACDF) and lumbar laminectomy.

RESULTS

Sixteen studies with a total of 370,195 patients met the inclusion criteria. Outpatient procedures were associated with younger patient age (mean difference [MD] −2.34, 95% credible interval [CrI] −4.39 to −0.34) and no diabetes diagnosis (odds ratio [OR] 0.78, 95% CrI 0.54–0.97). Outpatient procedures were associated with a lower likelihood of reoperation (OR 0.42, 95% CrI 0.16–0.80), 30-day readmission (OR 0.39, 95% CrI 0.16–0.74), and complications (OR 0.29, 95% CrI 0.15–0.50) and with lower overall costs (MD −$121,392.72, 95% CrI −$216,824.81 to −$23,632.92). Additional analysis of the national administrative data revealed more modest cost savings than those found in the meta-analysis for outpatient spine surgeries relative to inpatient spine surgeries. Estimated cost savings for both younger patients ($555 for those age 30–35 years [95% CrI −$733 to −$374]) and older patients ($7290 for those age 65–70 years [95% CrI −$7380 to −$7190]) were less than the overall cost savings found in the meta-analysis.

CONCLUSIONS

Compared to inpatient spine surgery, outpatient spine surgery was associated with better short-term outcomes and an initial reduction in direct costs. A selection bias for outpatient procedures toward younger, healthier patients may confound these results. The additional analysis of the national database suggests that cost savings in the outpatient setting may be less than previously reported and a result of outpatient procedures being offered more frequently to younger and healthier individuals.