Over the past 20 years, an increasing number of spinal surgeries have transitioned from inpatient to outpatient. This is due to multiple factors including the evolution of minimally invasive spine surgery (MIS), improved anesthetic regimens, lower rates of infection, and higher patient satisfaction when having surgery in outpatient facilities, and market forces— mainly the rising cost of health care.
The new era of health care reform allows opportunities for small, market- responsive outpatient spine surgery centers to capture segments of the market by providing high-quality care in a narrowly defined, specific area. Outpatient spine centers are essentially boutiques that deliver world-class care in a highly focused niche—what Harvard busi- ness professor Regina Herzlinger calls “focused factories” in her book, Market Driven Healthcare.
Shouldice Hospital for hernia surgery in Canada was the original focused factory. The Shouldice model proved that when a limited number of procedures are done in high volume by the same providers and staff, the outcomes are better, costs are lower, and patients are more satisfied.
Outpatient spine surgery allows the spine surgeon to maintain tight control of cost and quality, responding to the needs of not only the surgeon and the patient, but also insurance companies. The cost for outpatient spine surgery is 50 percent to 70 percent lower than for the same procedure performed in a hospital. MIS spine procedures are 30 percent to 60 percent less costly than traditional surgery. Besides the lower cost, MIS also offers the significant advantages of shorter recovery times and decreased rates of recurrence. In this era of cost containment, particularly given the demands of patients for healthy spines, outpatient and MIS spine surgery will continue to increase in frequency. Baby boomer patients, in particular, want more immediate results, quicker returns to active lifestyles and work, and to stay out of the hospital, if possible.
Presently, the spinal procedures frequently performed in an outpatient setting include the following:
- anterior cervical discectomies with fusions (one-, two-, and three-level)
- cervical disc arthroplasties (one- and two-level)
- cervical foraminotomies and posterior discectomies
- lumbar microdiscectomies
- lumbar laminoforaminotomies
- lumbar laminectomies
- MIS lumbar fusions including XLIFs, TLIFs, and interspinous process fusions
Cervical arthroplasties or total disc replacements (TDR) are an excellent example of a fairly new and very successful addition to the world of outpatient spine surgery. Based on the proven safety, cost effectiveness, clinical outcomes, and patient satisfaction with anterior cervical discectomy and fusion (ACDF), it was a natural next step to perform outpatient arthroplasties.
Arthroplasties offer quicker recovery than ACDF, preserve motion of the neck, and lessen the chance of devel- oping adjacent disc degeneration that might require further surgery. The five-year disc replacement data compared with fusion1 demonstrated that patients who underwent TDR had a 97.1 percent probability of no secondary procedures, compared with 85.5 percent for ACDF patients who did not experience a reoperation due to implant breakage or device failure. In addition, 2.9 percent of TDR patients had reoperations within five years of the initial surgery, compared with 14.5 percent of ACDF patients.
I have recently reported a consecutive series of 132 outpatient cervical arthroplasties, from 2009 through April 2013, with 92 percent improved symptoms, an average operative time of 60 minutes for one level and 80 minutes for two levels, and an average time to discharge of 3 hours. There was no significant morbidity and no mortality. There were no transfers to a hospital, no post-operative ER visits, and no late hospitalizations. The cost for outpatient cervical arthroplasty is lower than the cost for ACDF, and is less than 50 percent of the cost of the same procedure in a hospital.
Outpatient spine surgery will become increasingly more prevalent as new and enabling technologies continue to evolve, insurance companies and the government drive more health care to the outpatient setting for economic reasons, and patients become more educated about spine surgery options that meet their lifestyle expectations.
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