Identifying the Most Appropriate ACDF Patients for an Ambulatory Surgery Center: A Pilot Study Using Inpatient and Outpatient Hospital Data.

Abstract

Retrospective cohort analysis of prospectively collected data. Using a national cohort of patients undergoing elective anterior cervical discectomy and fusion (ACDF) in an inpatient/outpatient setting, the current objectives were to: (1) outline preoperative factors that were associated with complications, and (2) describe potentially catastrophic complications so that this data can help stratify the best suited patients for an ambulatory surgery center (ASC) compared with a hospital setting. ASCs are increasingly utilized for spinal procedures and represent an enormous opportunity for cost savings. However, ASCs have come under scrutiny for profit-driven motives, lack of adequate safety measures, and inability to handle complications. Adults who underwent ACDF between 2008 and 2014 were identified in the National Surgical Quality Improvement Program (NSQIP) database. Inclusion criteria were: principal procedure ACDF [Current Procedural Terminology (CPT) 22551, 22552], elective, neurological/orthopedic surgeons, length of stayof 0/1 day, and being discharged home. The primary outcome was presence of any complication. The secondary outcome was occurrence of potentially catastrophic complications. A total of 12,169 patients underwent elective ACDF with a length of stay of 0/1 day and were discharged directly home. A total of 179 (1.47%) patients experienced a complication. Multivariate logistic regression revealed the following factors were significantly associated with a complication: Charlson Comorbidity Index (CCI) >3, history of transient ischemic attack/cerebrovascular accident, abnormal bilirubin, and operative time of >2 hours. Approximate comorbidity score cutoffs associated with <2% risk of complication were: American Society of Anesthesiologists (ASA)≤2, CCI≤2, modified frailty index (mFI) ≤0.182. A total of 51 (0.4%) patients experienced potentially catastrophic complications. The current results represent a preliminary, pilot analysis using inpatient/outpatient data in selecting appropriate patients for an ASC. The incidence of potentially catastrophic complication was 0.4%. These results should be validated in multi-institution studies to further optimize appropriate patient selection for ASCs.