Vincent Rossi, Anthony Asher, David Peters, Scott L. Zuckerman, Mark Smith, Martin Henegar, Hunter Dyer, Domagoj Coric, Deborah Pfortmiller, Tim Adamson and Matthew McGirt
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.
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.
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%.
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.
Matthew J. McGirt, Scott L. Parker, Silky Chotai, Deborah Pfortmiller, Jeffrey M. Sorenson, Kevin Foley and Anthony L. Asher
Extended hospital length of stay (LOS), unplanned hospital readmission, and need for inpatient rehabilitation after elective spine surgery contribute significantly to the variation in surgical health care costs. As novel payment models shift the risk of cost overruns from payers to providers, understanding patient-level risk of LOS, readmission, and inpatient rehabilitation is critical. The authors set out to develop a grading scale that effectively stratifies risk of these costly events after elective surgery for degenerative lumbar pathologies.
The Quality and Outcomes Database (QOD) registry prospectively enrolls patients undergoing surgery for degenerative lumbar spine disease. This registry was queried for patients who had undergone elective 1- to 3-level lumbar surgery for degenerative spine pathology. The association between preoperative patient variables and extended postoperative hospital LOS (LOS ≥ 7 days), discharge status (inpatient facility vs home), and 90-day hospital readmission was assessed using stepwise multivariate logistic regression. The Carolina-Semmes grading scale was constructed using the independent predictors for LOS (0–12 points), discharge to inpatient facility (0–18 points), and 90-day readmission (0–6 points), and its performance was assessed using the QOD data set. The performance of the grading scale was then confirmed separately after using it in 2 separate neurosurgery practice sites (Carolina Neurosurgery & Spine Associates [CNSA] and Semmes Murphey Clinic).
A total of 6921 patients were analyzed. Overall, 290 (4.2%) patients required extended LOS, 654 (9.4%) required inpatient facility care/rehabilitation on hospital discharge, and 474 (6.8%) were readmitted to the hospital within 90 days postdischarge. Variables that remained as independently associated with these unplanned events in multivariate analysis included age ≥ 70 years, American Society of Anesthesiologists Physical Classification System class > III, Oswestry Disability Index score ≥ 70, diabetes, Medicare/Medicaid, nonindependent ambulation, and fusion. Increasing point totals in the Carolina-Semmes scale effectively stratified the incidence of extended LOS, discharge to facility, and readmission in a stepwise fashion in both the aggregate QOD data set and when subsequently applied to the CNSA/Semmes Murphey practice groups.
The authors introduce the Carolina-Semmes grading scale that effectively stratifies the risk of prolonged hospital stay, need for postdischarge inpatient facility care, and 90-day hospital readmission for patients undergoing first-time elective 1- to 3-level degenerative lumbar spine surgery. This grading scale may be helpful in identifying patients who may require additional resource utilization within a global period after surgery.