Trends in Utilization and Cost of Endoscopic Lumbar Decompression in Ambulatory Surgical Centers: A Nationwide Database Analysis From 2018 Through 2022.

Trends in Ambulatory Surgery Center Utilization for Otolaryngologic Procedures among Medicare Beneficiaries, 2010-2017.

Anesthesia for Office-Based Surgery: Are We Paying Too High a Price for Access and Convenience?

BACKGROUND:We describe the implementation of enhanced recovery after surgery (ERAS) programs designed to minimize postoperative nausea and vomiting (PONV) and pain and reduce opioid use in patients undergoing selected procedures at an ambulatory cancer surgery center. Key components of the ERAS included preoperative patient education regarding the postoperative course, liberal preoperative hydration, standardized PONV prophylaxis, appropriate intraoperative fluid management, and multimodal analgesia at all stages.METHODS:We retrospectively reviewed data on patients who underwent mastectomy with or without immediate reconstruction, minimally invasive hysterectomy, thyroidectomy, or minimally invasive prostatectomy from the opening of our institution on January 2016 to December 2018. Data collected included use of total intravenous anesthesia (TIVA), rate of PONV rescue, time to first oral opioid, and total intraoperative and postoperative opioid consumption. Compliance with ERAS elements was determined for each service. Quality outcomes included time to first ambulation, postoperative length of stay (LOS), rate of reoperation, rate of transfer to acute care hospital, 30-day readmission, and urgent care visits ≤30 days.RESULTS:We analyzed 6781 ambulatory surgery cases (2965 mastectomies, 1099 hysterectomies, 680 thyroidectomies, and 1976 prostatectomies). PONV rescue decreased most appreciably for mastectomy (28% decrease; 95% confidence interval [CI], –36 to –22). TIVA use increased for both mastectomies (28%; 95% CI, 20-40) and hysterectomies (58%; 95% CI, 46-76). Total intraoperative opioid administration decreased over time across all procedures. Time to first oral opioid decreased for all surgeries; decreases ranged from 0.96 hours (95% CI, 2.1-1.4) for thyroidectomies to 3.3 hours (95% CI, 4.5 to –1.7) for hysterectomies. Total postoperative opioid consumption did not change by a clinically meaningful degree for any surgery. Compliance with ERAS measures was generally high but varied among surgeries.CONCLUSIONS:This quality improvement study demonstrates the feasibility of implementing ERAS at an ambulatory surgery center. However, the study did not include either a concurrent or preintervention control so that further studies are needed to assess whether there is an association between implementation of ERAS components and improvements in outcomes. Nevertheless, we provide benchmarking data on postoperative outcomes during the first 3 years of ERAS implementation. Our findings reflect progressive improvement achieved through continuous feedback and education of staff.

Category: Ankle; Trauma Introduction/Purpose: Ankle fracture open reduction and internal fixation (ORIF) is one of the most commonly performed orthopaedic surgeries, which can be performed at a variety of surgical locations. However, there is very little data exploring the cost and efficiency of ankle fracture ORIF in different operative settings. Time-Driven Activity Based Costing (TDABC) is a novel accounting method used to accurately assign costs for various procedures by creating a process map of all personnel interactions as a patient moves through a care event. Further, it has been shown to more accurately allocate costs, as compared to traditional accounting systems. Our purpose is to evaluate cost and efficiency differences in ankle fracture ORIF at an outpatient ambulatory surgery center (ASC) versus a hospital setting. Methods: A prospective cohort study was performed at a single academic medical center involving four orthopaedic surgeons. Patients were enrolled with uni-, bi-, or tri-malleolar displaced ankle fractures undergoing ORIF. According to TD-ABC methodology, a process map was created for each peri-operative platform and hand-timed data was collected at each location (ASC=5, hospital=5) by a single observer. In addition, retrospective cost data was obtained from 181 surgical cases using our institution's existing cost accounting system (ASC=34, hospital=147). Average event times and care costs were calculated for both locations, and a process map outlining the steps of care was created for each surgical site, according to TDABC methodology. Data were analyzed to investigate the effects of surgical site on labor cost, efficiency, and provider time. Results: Overall, total direct cost was similar between locations (ASC=$10,837.43, hospital=$9,377.80; p=.114), although there were significantly higher direct costs in the hospital: perioperative/anesthesia (ASC=$2,532.61, hospital=$4,594.20; p<.001), pharmacy (ASC=$112.18, hospital=$349.74; p<.001), radiology (ASC=$17.67, hospital=$227.98; p<.001), and therapy (ASC=$28.23, hospital=$130.91; p<.001). However, medical supply costs, including implant costs, were significantly higher at the ASC (ASC=$7,835.14, hospital=$2,459.60; p<.001). Preoperatively, nurse assessment of the patient was significantly quicker in the hospital (ASC=14.65 min, hospital=5.10 min; p=.030), while patient transport to the operating room was significantly quicker in the ASC (ASC=1.20 min, hospital=2.60 min; p=.014). Case duration was significantly longer in the ASC (ASC=138.60 min, hospital=56.60 min; p=.005), which may have been influenced by case complexity, as there were more tri-malleolar fractures (n=2) and concomitate ankle arthroscopies (n=3) in that cohort. Conclusion: Overall, direct costs appear to be lower at the ASC than the main hospital, although efficiency of care delivery seems similar. Generally, there were small differences in the care continuum between the main hospital and ASC, though areas where improvement could be obtained include preoperative nurse assessment of the patient and efficacy of regional nerve block administration. Going forward, larger studies will be needed to further investigate these results.

National trends in medicare utilization and reimbursement fees for common shoulder arthroscopy procedures performed in ambulatory surgery centers from 2013 to 2022

Background:Ambulatory surgery or outpatient surgery is becoming increasingly common. In 2002, 63% of all operations performed in the United States were ambulatory procedures. Bariatric procedures performed in the United States have increased from 16,200 in 1992 to approximately 205,000 in 2007. In 2002, our center began offering laparoscopic Roux-en-Y gastric bypass (LRYGB) procedures on an outpatient basis for select candidates at an ambulatory surgery center (ASC). We subsequently added laparoscopic adjustable gastric band procedures (LAGB) in 2005.Methods:Between 2002 and 2008, 248 LRYGB and LAGB patients were carefully selected for ASC surgery by the bariatric surgeon and medical director. Extensive preoperative education was mandatory for all surgical candidates.Results:Since 2002, we have performed 248 bariatric cases at the ASC, including 38 LRYGB and 210 LAGB procedures. In this overall experience, 5 patients (2%) required readmission within 30 days of surgery, and 98.6% of LAGB patients were discharged the same day; 62% were discharged after a 4-hour to 6-hour stay in the ASC. All LRYGB patients remained in the ASC overnight and were discharge within 24 hours of their procedure. Weight loss results have been excellent.Conclusion:LAGB surgery can be safely performed in an ASC setting in most patients. LRYGB can be performed safely in the ASC setting with careful scrutiny and cautious selection of patient candidates.

Pioneering a Value-Based Purchasing Initiative for Ambulatory Surgery Centers in TRICARE West.

The transition of minimally invasive (MIS) spine surgery from the inpatient to outpatient setting has been aided by advances in multimodal analgesic (MMA) protocols. This clinical case series of patients demonstrates the feasibility of ambulatory MIS transforaminal lumbar interbody fusion (TLIF) and lateral lumbar interbody fusion (LLIF) procedures while using an enhanced MMA protocol. Consecutive MIS TLIF or LLIF procedures with percutaneous pedicle screw fixation and direct decompression in the ambulatory setting were reviewed. The procedures were performed using an MMA protocol. The ambulatory surgery center (ASC) did not allow for observation of patients for periods of time greater than 23 hours. We recorded patient demographics, perioperative, and postoperative characteristics. Fifty consecutive patients were identified from September 2016 to July 2019. Forty-one patients (82%) underwent MIS TLIF, and 9 patients underwent MIS LLIF (18.0%). All patients were discharged on the same day of surgery. The mean length of stay was 4.5 hours and 3.8 hours for the TLIF and LLIF cohorts, respectively. Our review of medical records revealed no postoperative complications following either the TLIF or the LLIF procedures. The present study of 50 consecutive patients is the largest clinical series of ASC patients undergoing lumbar fusion procedures in a stand-alone facility with no extended postoperative observation capability. While using MMA protocol within the ASC, no postoperative complications were observed for either MIS TLIF or LLIF procedures. All patients were discharged from the ambulatory surgical center on the day of surgery with well-controlled postoperative pain. 4. The MMA protocol is an essential aspect in transitioning minimally invasive lumbar spine surgery to the ASC. Our findings indicate that MIS lumbar fusion spine surgery with an enhanced MMA protocol can lead to safe and timely ASC discharge while minimizing hospital admission.

A recent study using Florida adverse event data found an increased risk of mortality in offices as opposed to ambulatory surgical centers. A major limitation of Florida adverse event data is the lack of uniform collection of the number of cases performed. The objective was to reassess the risk of mortality from physician office and ambulatory surgical center procedures using improved estimates of the numbers of cases performed in these settings. Adverse incident reports from March 2000 to March 2003 were obtained from the Florida Board of Medicine. We used data from the National Ambulatory Medical Care Survey and from the Medicare Current Beneficiary Survey to estimate the number of office procedures in Florida for both the general and the Medicare populations. The number of procedures performed and the number of deaths in ambulatory surgical centers was obtained from the Florida Agency of Healthcare Administration for the years 2000 through 2002. These data were used to calculate adverse event and mortality rates. For physician offices, the adverse event rates and mortality rates calculated per 100,000 procedures from National Ambulatory Medical Care Survey data were 2.1 and 0.41, respectively, and 0.24 and 0.10 using Medicare Current Beneficiary Survey data. For ambulatory surgical centers, the mean adverse event rate was 4.4 and the mean mortality rate was 0.90. Florida's adverse event data do not show higher adverse event rates in physician offices compared with ambulatory surgical centers. Incident reporting and public availability of incidents are important, as is standardization of reporting rules for both adverse events and number of procedures performed in different settings.

Ambulatory surgery centres are becoming an attractive alternative to hospital-based outpatient departments; however, limited data exist on their cost efficacy in a publicly funded health care model. In this study, we aimed to compare costs for ambulatory sports medicine procedures performed at an ambulatory surgery centre and a hospital outpatient department. We retrospectively identified patients who underwent rotator cuff repair, anterior cruciate ligament reconstruction (ACLR), or hip arthroscopy between January 2020 and August 2022. We collected demographic characteristics, procedural costs, and procedural data. We used 2-sample t tests to compare care-related costs between groups treated in an ambulatory surgery centre and hospital outpatient department. After controlling for age and concomitant procedures, we included a total of 132 patients for analysis. Patients who underwent hip arthroscopy or rotator cuff repair in an ambulatory surgery centre had significantly shorter duration of total operating room time, and procedural duration was equivocal (p > 0.1) between sites. Procedure time for ACLR was significantly shorter in the group treated in an ambulatory surgery centre than in the group treated in a hospital outpatient department (p = 0.01). The total case costs for the ambulatory surgery centre were significantly lower for hip arthroscopy ($3543, standard deviation (SD) $365 v. $6209, SD $681; p < 0.05), rotator cuff repair ($4259, SD $934 v. $5786, SD $934; p < 0.05), and ACLR ($3136, SD $459 v. $4821, SD $1511; p < 0.05), despite a lack of differences in associated disposable implant costs for ACLR and rotator cuff repair (p > 0.1). Material costs were significantly lower in the group receiving hip arthroscopy at an ambulatory surgery centre than in the group receiving the same procedure at a hospital outpatient department (p < 0.05). There were no differences in immediate 6-week postoperative care-associated costs between groups (p > 0.4). Ambulatory sports medicine procedures performed at an ambulatory surgery centre were associated with significantly reduced operating room time and total cost compared with matched cases performed via a hospital outpatient department. Ambulatory surgery centres provide an opportunity to improve cost efficacy and reduce wait-lists for surgical care.

Spinal procedures are increasingly conducted as outpatient procedures, with a growing proportion conducted in ambulatory surgery centers (ASCs). To date, studies reporting outcomes and cost analyses for outpatient spinal procedures in the US have not distinguished the various outpatient settings from each other. In this study, the authors used a state-level administrative database to compare rates of overnight stays and nonroutine discharges as well as index admission charges and cumulative 7-, 30-, and 90-day charges for patients undergoing outpatient lumbar decompression in freestanding ASCs and hospital outpatient (HO) settings. For this project, the authors used the Florida State Ambulatory Surgery Database (SASD), offered by the Healthcare Cost and Utilization Project (HCUP), for the years 2013 and 2014. Patients undergoing outpatient lumbar decompression for degenerative diseases were identified using CPT (Current Procedural Terminology) and ICD-9 codes. Outcomes of interest included rates of overnight stays, rate of nonroutine discharges, index admission charges, and subsequent admission cumulative charges at 7, 30, and 90 days. Multivariable analysis was performed to assess the impact of outpatient type on index admission charges. Marginal effect analysis was employed to study the difference in predicted dollar margins between ASCs and HOs for each insurance type. A total of 25,486 patients were identified; of these, 7067 patients (27.7%) underwent lumbar decompression in a freestanding ASC and 18,419 (72.3%) in an HO. No patient in the ASC group required an overnight stay compared to 9.2% (n = 1691) in the HO group (p < 0.001). No clinically significant difference in the rate of nonroutine discharge was observed between the two groups. The mean index admission charge for the ASC group was found to be significantly higher than that for the HO group ($35,017.28 ± $14,335.60 vs $33,881.50 ± $15,023.70; p < 0.001). Patients in ASCs were also found to have higher mean 7-day (p < 0.001), 30-day (p < 0.001), and 90-day (p = 0.001) readmission charges. ASC procedures were associated with increased charges compared to HO procedures for patients on Medicare or Medicaid (mean index admission charge increase $4049.27, 95% CI $2577.87-$5520.67, p < 0.001) and for patients on private insurance ($4775.72, 95% CI $4171.06-$5380.38, p < 0.001). For patients on self-pay or no charge, a lumbar decompression procedure at an ASC was associated with a decrease in index admission charge of -$10,995.38 (95% CI -$12124.76 to -$9866.01, p < 0.001) compared to a lumbar decompression procedure at an HO. These "real-world" results from an all-payer statewide database indicate that for outpatient spine surgery, ASCs may be associated with higher index admission and subsequent 7-, 30-, and 90-day charges. Given that ASCs are touted to have lower overall costs for patients and better profit margins for physicians, these analyses warrant further investigation into whether this cost benefit is applicable to outpatient spine procedures.

Study DesignRetrospective Cohort Study.ObjectiveDespite innovations in minimally invasive (MI) techniques for sacroiliac joint fusion (SIJF), trends in utilization and associated costs remain unclear. In this study, we assessed these trends and costs in a database of privately insured patients.MethodsRecords of open and MI SIJFs were queried from the 2007-2021 MarketScan Databases with CPT codes. Net payments made by insurance carriers were identified, as were out-of-pocket payments made by patients for each encounter. Regression was used to model utilization, payments, and costs.Results4124 SIJFs were identified, 1626 (39.4%) of which were MI SIJF. SIJF utilization increased by 1176.2% throughout the study period (P < .001). However, open SIJF utilization peaked in 2012. Open SIJF utilization was not significantly associated with time (P = .18). By contrast, the peak utilization for MI procedures occurred in 2021. Spine surgeons’ volume of MI SIJF increased by 258% over the study period (P < .001), while nonsurgeon volume of MI SIJF increased by 990.9% (P < .001).ConclusionPrivately insured patients have increasingly utilized SIJF over the past several years. This is predominantly due to the adoption of MI techniques by spine surgeons and nonsurgeons.

ObjectiveThe systematic review aims to determine the safety of conducting non-upper airway surgery in an ambulatory surgery center (ASC) for OSA patients.Data sourcesA comprehensive search was conducted from MEDLINE, Embase, CENTRAL, and Scopus from inception through February 2023.Review methodsStudies including non-upper airway surgery done in ASC settings were identified. Risk of bias was assessed using the Murad Tool and Newcastle-Ottawa scale. Primary outcomes were 24 hour complications and unplanned admission rates.ResultsFrom 9313 studies, 13 non-OSA studies with 31,200 OSA participants and 318,709 non-OSA participants were identified. Severe complications were rare and tended to occur within the first 4 hours of the postoperative period. While a majority of smaller scale studies found no significant difference in unplanned admissions, large scale studies with multivariate analysis find OSA to be an independent risk factor for unplanned admission and 30-day complications. However, large scale ASC studies have found that with proper selection and perioperative interventions, OSA patients can undergo outpatient surgery at ASCs safely.ConclusionsOSA patients with mild or controlled comorbidities can safely undergo ambulatory non-OSA surgery in ASCs.OtherThe protocol for this review was registered with the PROSPERO database (Registration number: CRD42023415162).

See Article, p 699 GLINDA: Are you ready now? DOROTHY: Yes… GLINDA: Then close your eyes, and tap your heels together three times. And think to yourself -- "There's no place like home; there's no place like home; there's no place like home." DOROTHY: There's no place like home. There's no place like home. There's no place like home. There's no place like home. —The Wizard of Oz (1939) Noel Langley, Florence Ryerson, and Edgar Allen Woolf The concept of multimodal postoperative recovery programs—commonly referred to as enhanced recovery after surgery (ERAS) programs or "fast-track surgery"—was first proposed by Kehlet and Wilmore1 more than 20 years ago, when it was recognized that isolated, single clinical interventions were inadequate in addressing the problem of multifactorial perioperative complications and morbidity. Although simple in principle, collective experience and reported data during the interim 20 years have observed relatively slow progress in disseminating, implementing, and sustaining ERAS programs.2,3 This can likely be partly explained by the requirement for multidisciplinary collaboration, as well as cultural and organizational factors that frequently impede fundamental change in traditional patient care.2,3 Furthermore, the initial protocols for open colonic surgery included only a few essential principles of ERAS, whereas, the advent of more multifaceted and complicated ERAS programs and protocols have hampered implementation.2 From the contemporary perspective, the main issue still to resolve with ERAS programs is how to make further progress in achieving the ultimate goal of a risk-free surgical procedure.2 Thus future ERAS strategies should include a shift away from the conventional endpoints of early recovery and shortened length of stay to place more emphasis instead on mitigating postdischarge problems.2,4 However, at least in the United States, there are major health care policy changes that mandate continued attention on postoperative early recovery and reduced length of stay. No matter what the postoperative priorities, fundamentally transforming the traditional structures and processes of surgical and anesthetic care can indeed be challenging. Fortunately, there are innovators paving the way. In this issue of Anesthesia & Analgesia, Tokita et al5 provide a comprehensive description of a very innovative migration of complex cancer surgery from the hospital setting to an ambulatory extended recovery (AXR) setting of the Josie Robertson Surgery Center (JRSC) at Memorial Sloan Kettering Cancer Center (MSKCC). A key first question is "What is ambulatory extended recovery after surgery?" In 2003, the International Association for Ambulatory Surgery (IAAS) provided very pertinent, international consensus-based terminology (Figure 1).6 The IAAS has also made the following fundamental functional distinction:7Figure 1.: Basic terminology related to surgical encounter timeframes and synonyms.6 True ambulatory surgery is where patients are admitted, operated on, and discharged during the time frame of 1 working day (6–8 hours). There is no overnight facility stay. Ambulatory surgery with extended recovery is where patients are admitted, operated on, and stay for 1 night postoperatively with an overall stay up to 23 hours. To fully realize the potential expansion of ambulatory surgery, one must first understand the definition and current limitations of the different types of ambulatory surgery facilities. An ambulatory surgery center (ASC) is a freestanding facility that typically performs surgical procedures that do not require overnight stay. An ASC is not required to be associated with a hospital. An ambulatory surgery facility, which is not associated with a hospital, can perform surgical procedures stipulated on the current US Centers for Medicare & Medicaid Services (CMS) ASC covered procedures list. However, such an independent ASC cannot perform any procedures on the current Medicare inpatient-only (MIO) list (Figure 2). This significantly differs from a hospital outpatient department (HOPD), which is 100% owned by a hospital and is not limited in its procedural scope. Hospital-owned facilities can perform ambulatory surgery within the hospital, in a facility attached to the hospital, or in a facility physically separated from the hospital. In the United States, an HOPD is reimbursed at a markedly higher rate by CMS than an independent ASC. There are other significant differences between an independent ASC and an HOPD (Figure 2).8–10Figure 2.: Characteristics of an independent ASC versus a HOPD as defined by the US CMS.8–10 ASC indicates ambulatory surgery center; CMS, Centers for Medicare & Medicaid Services; HOPD, hospital outpatient department.Tokita et al5 accordingly note that organizationally, (a) the JRSC is part of the MSKCC and operates as a hospital-associated outpatient clinic; (b) the JRSC is attached to the Memorial Hospital ambulatory license; and (c) all JRSC staff are employed at MSKCC. These specific organizational aspects of the JRSC might make its AXR model neither feasible nor appropriate in a conventional ASC—particularly from a financial perspective. According to US CMS Rule 42 C.F.R. §412.3(e), a hospital admission is classified as inpatient if the surgical procedure is on the MIO list, or if the provider expects that the hospital stay will cross 2 midnights. If a surgical procedure on its MIO list is performed in an outpatient setting or with postoperative observation status (minimum of 8 hours, but <24 hours), CMS might refuse to reimburse for the procedure. If a surgery is not on its MIO list, CMS will only reimburse for postoperative inpatient status if clinical documentation can justify the need for a greater than 2 midnight stay.11,12 Importantly, a documented comprehensive preoperative patient assessment, which applies objective, well-defined clinical criteria for recommending postoperative inpatient versus outpatient status,13 can validly and compliantly be provided by a Perioperative Medicine program and clinic.14 The initial, major challenge at MSKCC was thus identifying the types of surgical procedures—with historical average inpatient hospital stays of 2–4 days—that with suitable patient selection and management, could be safely discharged home after a single overnight stay.5 While technically qualifying as ambulatory or outpatient procedures from a regulatory standpoint and payer perspective, Tokita et al5 distinguish these more complex, short-stay, AXR procedures from conventional outpatient procedures after which the patient recovers and is discharged home in a few hours. Here again, a Perioperative Medicine program and clinic can play a very important role in implementing patient selection criteria and undertaking needed medical optimization for an AXR procedure.15,16 The MSKCC leadership and other organizational stakeholders were guided by a set of principles and a series of related questions in developing the JRSC, which are not only illustrative but also vital for other entities pursuing any such pioneering health care delivery model:5 How can we become national leaders in delivering high-quality and cost-effective day and short-stay surgery? How can we maximally standardize processes and procedures? How do we continually assess progress to innovate and improve? How can we apply new technology to streamline processes and allow staff to focus on patients? What are the optimal roles for nurses and advanced practice providers within this short-stay environment? Most importantly, how can we ensure that the needs and experience of the patient and their loved ones are considered and prioritized in everything we do? With more extensive surgical procedures being performed in an ambulatory setting, it is necessary that patient safety is not jeopardized. The ERAS principles that allowed the migration of these surgical procedures to the outpatient setting must still be applied. This would reduce unplanned hospital transfers from the ambulatory facility, as well as mitigate emergency department visits and acute care hospital readmission after discharge. These adverse outcomes might negate the cost-effectiveness of moving the surgical procedures to the outpatient setting. Future studies should investigate approaches to identify and manage postdischarge complications. This could be achieved with real-time electronic symptom monitoring systems similar to the one used by Tokita et al.5 In addition, such electronic systems can provide patient self-management advice that could reduce unnecessary emergency department visits. These systems could also directly assess patient-reported outcomes. Such monitoring would also allow identify the timeline of complications and classify them as medical versus surgical, and determine approaches toward preventing them. Medical complications can be addressed through modifying patient selection criteria and perioperative management. In contrast, surgical complications can be addressed through reassessment of perioperative care, as well as surgical technique and expertise. In summary, there has been a continued, and likely future sustained expansion of the number of ASCs and the number of procedures performed in ASCs, particularly in the United States but also worldwide.17–19 As insightfully observed by Philip,10 such outpatient surgery has been a success in the United States because of 2 important reasons: (1) a focus on efficiency, quality, and cost of care and (2) a focus on the patient and the role of humanism in medicine. The pioneering work of Simon and colleagues in creating the JRSC at MSKCC exemplifies these 2 fundamental tenets of health care value and humanism.5 Nevertheless, in order for AXR to achieve its ultimate yet still potential positive health care impact, it must be financially sustainable in an ASC setting. At least in the United States, this will require major, progressive changes to current CMS regulations and reimbursement. DISCLOSURES Name: Thomas R. Vetter, MD, MPH. Contribution: This author helped write and revise the manuscript. Name: Girish P. Joshi, MBBS, MD, FFARCSI. Contribution: This author helped write and revise the manuscript. This manuscript was handled by: Jean-Francois Pittet, MD.

Introduction Current literature is limited in assessing nationwide trends of penile prosthesis (PP) placement in the United States largely due to a lack of data on outpatient PP placement. Particularly no nationwide comparison of ambulatory surgery center (ASC) versus inpatient hospital (IH) PP placement has been published. Objective Our objective is to determine the trends of PP placement in ASCs vs IHs utilizing representative nationwide data. Additionally, we examined patient demographics that are associated with the setting for PP placement. Methods Inpatient and outpatient encounters for PP placement between 2016 and 2019 were analyzed using data from the Nationwide Inpatient Sample (NIS) and the Nationwide Ambulatory Surgery Sample (NASS) from the Healthcare Cost and Utilization Project (HCUP). These are the largest publicly available inpatient and ambulatory surgery databases available in the United States. PP operations were identified by CPT and ICD-10-PCS codes. Subsequent analysis was performed using the established weighting provided by the HCUP, which utilizes stratified cluster sampling to create national estimates. Comparisons of demographics were performed using t-tests and chi-square tests with a p-value for significance &amp;lt;0.05. Results Over the study period, there were 67,722 PP placements in the United States. The percentage placed in ASCs was 93.1%. In 2016, 16,290 PP placements occurred, of which 92.3% were placed in ASCs. Comparatively in 2019, there was a 7.3% increase (17,473) in the number of PP placements, with 94.5% placed in ASCs (p&amp;lt;0.01). Over the study period, 33,008 PP placements were performed in the South (93.8% ASCs), 12,481 in the Midwest (94.6% ASCs), 12,192 in the Northeast (92.4% ASCs), and 10,040 in the West (90.1% ASCs, p&amp;lt;0.01). The average age of patients receiving a PP placement was 64.4 in ASCs compared with 62.5 in IHs (p&amp;lt;0.01). The average cost associated with PP placement in ASCs was $25,935, about half the cost of inpatient settings, which averaged $51,594 (p&amp;lt;0.01). Of all PP implants, the primary payer was medicare for 57.1% (38,660; 93.1% ASCs), medicaid for 4.4% (2980; 86.6% ASCs), private for 33.6% (22,778; 94.3% ASCs), and self-pay for 1.1% (768; 90.9% ASCs, p &amp;lt;0.01). Conclusions Our results suggest that the number of PP placements is consistently rising each year, with an increasing majority of PP placements performed in ASCs. The procedure costs roughly half on average when performed in ASCs compared to IHs. Further investigation is needed to compare complication rates and outcomes of PP placements in ASC versus IH. Disclosure No