Blue Chip: Surgeon Stories
The Outpatient Evolution in Spine Surgery
Evolution, Not Revolution
For more than a decade, there’s been a steady progression of spine surgeries away from hospital ORs and toward the surgical suites at outpatient facilities and ambulatory surgery centers (ASCs). This fundamental shift has sometimes been described as a revolution, but in my view it’s been more like a natural evolution, and very similar to a process of continuous improvement. As a surgeon, I first grasped what was coming when I saw that overnight hospital stays were unnecessary for many spine surgery patients, some of whom I classified as outpatient anyway. Those overnight stays were largely a formality, and the need for them has been eliminated today, thanks to big improvements in medication, instrumentation and imaging.
Many neurosurgeons I know are interested in handling spine surgeries at outpatient facilities, but have questions about managing risk as they make the transition from inpatient. That’s just as it should be. In developing ASCs with Blue Chip, I’ve worked with many surgeons who’ve successfully made the transition, and together we’ve outlined a few critical steps to take, from understanding the reasons for the evolution to taking practical action to begin the process. The balance of this article will address those steps.
The Evolutionary Factors
A great first step is to recognize the many forces that have made outpatient spine surgery possible and, in many cases, preferable. From the clinical perspective, technological advancements have played a large role. Imaging, operating microscopes, retraction systems, minimally invasive instrumentation – almost every thing in the OR has been enhanced in recent years. Pre- and post-operative drugs have also improved dramatically. From the moment surgery is complete and throughout the following few days, we have access to drugs that make it easier to manage pain for patients, without debilitating them. Improved pre-operative drugs and anesthesia techniques minimize side effects and shorten recovery times. Over-sedation is much less a problem than it used to be.
Through extensive research, surgical techniques have also changed for the better, giving surgeons many more options in finding the best procedures for individual patients. For instance, laminectomies have become less risky as the use of minimally invasive techniques has increased. ACDFs, minimally invasive fusions, multi-level decompressions, disc arthroplasties – many procedures that were considered cutting-edge not so long ago are now commonplace, and are often handled in outpatient environments.
Collectively, technological, pharmaceutical and clinical advancements have enabled patients to be up and about more quickly after surgeries, even the more complicated procedures. That’s made outpatient environments highly viable for the vast majority of spine surgeries. Such is the nature of medical progress.
The transition to outpatient also represents a natural progression in the role of neurosurgeons. As a specialty, we’re repositioning ourselves to take a leading role in redefining the standard of care, particularly in spine care, and the increasing use of minimally invasive techniques. Since neurosurgeons handle about 75% of all spine care cases, these techniques are likely to grow more popular, as will the use of ASCs.
The Economic View
As with many things in healthcare, economics have shaped the transition to outpatient. Insurers and government payers were pleased to find ways to get patients up and moving about sooner, and to reduce the lengths of expensive hospital stays. In this sense, patients, payers and physicians share a common interest; a faster healing process is good for everyone. Payers benefit from the lower costs of treatments handled at ASC, while physicians benefit from the higher margins. That’s a “win-win.”
As for the financial impact on patients, much depends on the treatment in question, as well as the patients’ health plan. In general, though, patients don’t pay a premium to undergo surgery at ASCs and may realize some out-of-pocket savings. Certainly they save on the cost of parking, which can be sky-high at many hospitals.
Patients have become big fans of outpatient spine surgery centers.
But it’s largely for non-financial reasons that patients have become fans of outpatient surgeries. Minimally invasive treatments, which are the standard for ASCs, equate to less trauma and pain and, as we’ve said, faster recoveries. Patient experience matters a lot, and well-managed ASCs offer warmer, more comfortable and more welcoming environments than your average hospital. When patients are able to visit the ASC before their treatment, the familiarity with the staff and facility helps them feel more comfortable. Practically speaking, patients and their family members like not having to navigate huge hospital complexes.
Managing Transition Risk
Successfully making the transition to outpatient environment involves the careful consideration of many questions. But, our colleagues at Blue Chip-developed ASCs point to a number of key steps that represent something of a checklist for surgeons to consider, especially in terms of risk management. It’s not a comprehensive list, but it is helpful to frame the key issues and lay the foundation for a smooth transition.
Patient Selection: Not every case is ideal for ASCs. Therefore, risk management for outpatient environments starts with careful assessment and evaluation of the patient. Obviously, the younger and the healthier the patient, the more likely he or she will be a good candidate for outpatient surgery. Probably the biggest concern is with complex treatments like anterior neck or spine procedures, which have a higher risk of hematoma. Obese patients and those with a history of respiratory problems often don’t make sense for outpatient spine surgeries. (For more insights into patient selection, please reference the Perspectives article by Dr. John Caruso.)
Managing Patient Perceptions: A good way to build patient comfort and confidence in outpatient spine surgeries is to handle epidural steroid injections (ESIs) at an ASC. The treatment usually takes no more than 20 minutes, and patients don’t have to change out of their street clothes. They can relax for an hour or two afterwards and go home. If they must come back to the ASC later for a surgical procedure, patients and their families will have a better feel for the staff, routine and tempo of being treated at ASCs.
Building Surgeon Confidence: Patient perceptions are largely determined by medical personnel. If you, as a surgeon, are confident handling spine surgeries on an outpatient basis, your patients will also be confident. Referring physicians and support staff should also make it clear that ASCs are perfectly suitable for these procedures, and indeed preferable to hospitals. To build their own comfort level with outpatient spine surgeries, some of our colleagues start handling surgeries on an outpatient basis at hospitals. That’s especially true for surgeons who are waiting for new ASCs to be built.
Post-Operative Care: Outpatient environments can give surgeons more control over post-operative care. Specifically, they, or their staff, can provide better and more personalized oversight and care instructions at the time of discharge. They can share detailed instructions about when and how to take medicines, how to deal with pain and what to do if anything goes wrong. Again, the reduced trauma of minimally invasive techniques and better drugs give surgeons a lot to work with. Compare that to typical hospital environments, where surgeons have little or no influence over the discharge process.
Responding to Complications: Surgeons who remain skeptical about outpatient spine surgery seem most worried about managing the complications, which can sometime arise. As for hematomas, the incidence is low, and all of us had to deal with them. In outpatient cases, you must be certain you can get to the ER in time to re-explore, if necessary. In some ways, preparing for complications in outpatient environments is the same as in traditional inpatient settings; that is, it’s primarily a matter of planning and foresight.
Staffing: Physicians control the staff at ASCs – that’s a big advantage of operating at an ASC. Surgeons love working with staff they trust and feel comfortable with, which is also a big plus for ensuring quality outcomes. It’s easier to hire who you want, and train a small, focused staff in an ASC, than trying to manage large hospital staffs. With outpatient surgeries, you’ll want staff – including OR nurses and anesthesiologists – who are skilled and experienced with specific treatments. You have more say in evaluating the performance of everyone in the OR and you can more directly interact with your anesthesiologist to plan ahead and solve problems. There are more anesthesiologists who have grown comfortable working in outpatient environments. That’s good news.
Technology: With so much new technology (and more being released all the time), it’s easy to overestimate the importance of tools and instruments. In many ways, technology is a red herring when it comes to transitioning spine treatments from inpatient to outpatient. I know surgeons who prefer to use older (but still highly useful) tools in their outpatient ORs. The point is, you don’t need the latest, most expensive instruments to succeed with outpatient spine surgery. In my experience, it’s the more humane parts of medicine – patient assessment, building the right OR team, and self-confidence – that enable smooth transitions to outpatient environments.
The Bottom Line
The evolution to outpatient spine surgery seems to be reaching critical mass lately, but truly it’s been a long-term process of incremental progress. I believe the evolution will continue to gather steam as technology continues to improve, patient expectations shift relative to minimally invasive surgery, and more surgeons (and neurosurgeons in particular) receive training in outpatient environments.
Further, the business and medical issues are closely aligned, especially in terms of having the best equipment and quality staff. As more surgeons conduct successful outpatient spine surgeries, more will grow interested in developing their own facilities. It’s no wonder that the majority of analysts predict rapid growth in the number of spine surgery centers. The market – including patients, payers and surgeons – is ready and the time is right.
