The last JBJS fast-track article cited the need for clearer definitions of “elective” orthopaedic surgery amid the COVID-19 pandemic. As if in response to that, the newest JBJS fast-track article by DePhillipo et al. further explores the moving-target distinction between elective and necessary orthopaedic surgery. The authors also delineate the possible role of ambulatory surgical centers (ASCs) in handling outpatient surgical procedures that were previously scheduled for inpatient facilities.
Absent clear recommendations about which procedures should be considered important enough to be performed in ASCs, DePhillipo et al. offer the following general suggestions:
- Acute and/or disabling injuries to health-care workers, first responders, and members of the military and police and fire departments
- Osseous fractures and/or irreducible joint dislocations
- Wound/joint infections or postoperative wound dehiscence
- Pathologies that could lead to long-term disability and chronic pain if acute surgical management is delayed
The most specific and valuable information in this article is a table that lists, joint-by-joint, acute orthopaedic injuries that the authors deem “surgically necessary” or “elective-urgent procedures,” along with justifications for each. The authors note that the list is far from “a medical directive or standard of care,” but they propose an interesting rationale for fewer restrictions on elective procedures for low-risk individuals: those who are currently restricted from work or unemployed would have the opportunity to have and recover from surgery and be ready to reenter the work force when the time comes.
Finally, the authors offer best-practice guidance for ASCs in the current climate:
- Limit visitors to all but minor patients, the mentally/physically disabled, and elderly patients who require assistance.
- Administer appropriate screening of patients and staff for signs of illness or other risk factors.
- Ensure that all who are present during intubation and extubation have access to appropriate personal protective equipment, including N95 masks.
The September 16, 2015 JBJS study by Robinson et al. offers clear proof that many of our patients are sensitive to price when it comes to choosing where to go for arthroscopic surgery of the knee or shoulder. This phenomenon began at least a decade ago when employers began shifting the cost burden of health care coverage onto their employees. The findings from Robinson et al. confirm the increasing strength of this effect.
The authors analyzed administrative data from the California Public Employees’ Retirement System (CalPERS) to evaluate the impact of so-called “reference-based benefits” on patient choice for the setting of arthroscopy—hospital-based outpatient departments or freestanding ambulatory surgery centers (ASCs). Reference-based benefits require patients to pay the cost differential between an insurer-established “contribution limit” and the actual price charged by a facility.
Within two years of shifting to reference-based benefits, CalPERS-covered patients increased their utilization of ASCs by 14.3% for knee arthroscopy and by 9.9% for shoulder arthroscopy, with corresponding decreases in the use of hospital-based facilities. Meanwhile, CalPERS reduced overall spending on these procedures by 13%, and there were no significant before-and-after differences in 90-day complication rates.
These findings lead one to ask what added benefits patients receive from hospital-based outpatient surgery — Is it a safer environment or more convenient? Are the results more predictable? I think not, and on that basis the added charges are not justified.
Now that Robinson et al. have provided us with hard data on the impact of surgical-setting charges on patient behavior, we need to think about providing additional information that our patients would find helpful. We should, for example, move forward with increasing transparency on surgery fees and charges for outpatient visits, imaging, and durable medical goods. The time is right for us to do our part in eliminating this “black box” aspect of orthopaedic care.
At the same time, as commentators Kern Singh and Junyoung Ahn note, because payers will continue to define value according to their criteria, “orthopaedic surgeons should increase their involvement in this process to ensure the balance between outcome benefits and associated costs.”
Marc Swiontkowski, MD
Improvements in surgical procedures continue to evolve at a brisk pace. It seems that, every year, incisions become smaller and operations, more streamlined. Certain operations that in the past would only have been performed as inpatient procedures are now being considered for outpatient surgery with same-day discharge.
In the May 2015 issue of JBJS Reviews, Kurd et al. review the ability to perform spine surgery in an ambulatory setting. The authors note that anterior surgical discectomy and fusion is now commonly performed in an ambulatory surgery center and, if patients are carefully selected, lumbar microdiscectomies and laminectomies can be performed in an ambulatory surgery center as well. The authors stress the importance of an established transfer plan to a hospital when needed and the ability to treat neurologic complications if they occur. Most importantly, the ability to treat potentially serious complications in a timely manner is critical.
The rationale for performing spine surgery in an ambulatory surgery center is primarily for the convenience of the patient. The authors note that friendly staff, minimal wait times, efficiency, and perhaps ease of parking allow for ambulatory surgery centers to have overall patient satisfaction rates of up to 92%. In addition, by moving procedures out of a hospital and into ambulatory surgery centers, the cost savings to Medicare alone have been substantial.
Practice guidelines for some of the important decisions regarding patients undergoing anesthesia have been established by the Society for Ambulatory Anesthesia (SAMBA), whose goal is to provide guidance on the use of anesthesia in an ambulatory setting. Recommendations such as avoiding general anesthesia when possible, using propofol for induction and maintenance, avoiding nitrous oxide and other volatile anesthetics, minimizing the use of opioids, and maintaining adequate hydration are among the most important. In addition, SAMBA recommends that all diabetic patients undergoing surgery at an ambulatory surgery center should have a hemoglobin A1C of <7%.
While several reports have established the safety of performing cervical surgical spine surgery in an ambulatory surgery center, concerns still exist regarding the treatment of life-threatening events such as an epidural hematoma. Other rare complications such as vertebral artery injury or esophageal injury require intraoperative consultation with another surgery subspecialty such as vascular surgery or otolaryngology, and such consultations may not be available in an ambulatory surgery center.
The spinal procedure that is most commonly performed on an outpatient basis is a single-level lumbar decompression. Microdiscectomy is also frequently performed. This article reviews the largest prospective series of outpatient lumbar discectomies to date and indicates that the role of proper patient selection is paramount and that comorbidities such as obesity, chronic obstructive pulmonary disease, and a history of stroke increase the risk of needing hospitalization. As the use of the ambulatory setting for spinal surgery continues to evolve, further delineation of the ideal conditions and requirements will become evident. In the meantime, elderly patients and patients with multiple comorbidities may be better managed at a hospital as they are at an increased risk of requiring hospitalization.
Thomas A. Einhorn, MD
Editor, JBJS Reviews