Ambulatory Surgery Center Research Articles

Robotic-Arm Assisted Total Hip Arthroplasty: Workflow Optimization and Operative Times

Robotic-arm assisted total hip arthroplasty (RATHA) has been demonstrated to offer several benefits, such as increased accuracy in the placement of implants, improved patient outcomes and reduced complications such as dislocations in total hip arthroplasty. However, the potential increase in surgical time may sway some practitioners to hesitate adopting this technology, despite its benefits. Studies of RATHA learning curves have demonstrated that time neutrality can be achieved, but do not describe an efficient workflow. This paper lays out a process to achieve an optimal RATHA workflow and efficiencies in an ambulatory surgery center and presents timing data from 105 cases. We demonstrate that the learning curve for implementing RATHA can be navigated such that providers can offer the clinical benefits of RATHA to their patients without increasing operative or overall perioperative patient time.

Efficiency and perceived safety of foot and ankle procedures performed on the preoperative stretcher versus operating room table.

Foot and ankle surgeons often perform minor surgeries on the preoperative stretcher instead of the operating room table. We examined whether stretcher-based and operating room table-based procedures differed with respect to operating room efficiency and staff perceptions. We retrospectively reviewed medical records of patients undergoing minor foot and ankle surgery at an ambulatory surgery centre. We collected 'time to start', the duration between patient arrival in the operating room and incision time, and 'time to exit', the duration between procedure end time and patient exit from the operating room. Staff were surveyed regarding their perceptions of stretcher-based and operating room table-based procedures. 'Time to start' was significantly shorter for stretcher-based procedures, but 'time to exit' was not. Seventeen (81%) staff members thought stretcher-based procedures increased operating room efficiency. Thirteen (62%) thought stretcher-based procedures bettered staff safety. Nineteen (91%) thought stretcher-based procedures were equivalent to or better than operating room table-based procedures for patient safety. Most (67%) would recommend stretcher-based procedures. We found small but significant time savings associated with stretcher-based procedures. Without adapting surgical scheduling practices, the impact of stretcher-based procedures on overall operating room efficiency is questionable. Nevertheless, the majority of OR staff think stretcher-based procedures increase OR efficiency and are safer for staff. Level IV, Retrospective case series.

Spinal Versus General Anesthesia for Outpatient Total Hip and Knee Arthroplasty in the Ambulatory Surgery Center: A Matched-Cohort Study

BackgroundSpinal anesthesia is the predominant regimen in outpatient total joint arthroplasty (TJA), but induction often is unsuccessful, unobtainable, or against patient preference. We compared outcomes of same-day discharge (SDD) TJA with spinal versus general anesthesia in a free-standing ambulatory surgery center (ASC). MethodsWe took 105 general anesthesia TJA and one-to-one nearest-neighbor matched them to 105 spinal anesthesia TJA over 7 years at 1 ASC. The rate of successful SDD, minutes to discharge, postoperative pain and nausea, and 90-day complications were compared. Postanesthesia care unit outcomes were additionally stratified by spinal anesthetic (mepivacaine versus bupivacaine). ResultsAll spinal anesthetic patients underwent SDD compared with 103 (98%) general anesthetic patients (P = .498). Mepivacaine spinal anesthesia patients spent the fewest minutes in postanesthesia care unit prior to discharge from the facility (206), followed by general anesthesia (227), and bupivacaine spinal anesthesia (291; P < .001). General anesthesia patients had the highest levels of pain at 1 hour (5.2 versus 1.5 versus 1.5) and 2 hours (3.2 versus 2.0 versus 1.3) postoperatively, and rates of nausea (48 versus 22 versus 28%) compared with mepivacaine and bupivacaine spinal anesthesia, respectively. The 90-day complications (6 versus 7), admissions (1 versus 3), and reoperations (5 versus 2) were similar among spinal and general anesthesia, respectively (P ≥ .445). ConclusionsBoth spinal and general anesthesia led to reliable SDD with similar 90-day complication rates. General anesthesia facilitated faster discharge from the ASC compared with bupivacaine spinal anesthesia but led to higher levels of pain and incidence of nausea postoperatively. Level of EvidenceLevel 3, Retrospective Cohort Comparison.

Facility Fees for Colonoscopy Procedures at Hospitals and Ambulatory Surgery Centers

This cross-sectional study investigates commercial facility fee differences for colonoscopy procedures between US hospitals and ambulatory surgery centers located within the same county and contracting with the same insurers.

Improving Access to Specialty Pediatric Care: Innovative Referral and eConsult Technology in a Specialized Acute Care Hospital.

Background: The COVID-19 pandemic has exacerbated wait times for pediatric specialty care. Transformative technologies such as electronic referral (eReferral-automation of patient information) and electronic consultations (eConsult-asynchronous request for specialized advice by primary care providers) have the potential to increase timely access to specialist care. The objective of this study was to present an overview of the current state and characteristics of referrals directed to a pediatric ambulatory medical surgery center, with an emphasis on the innovative use of an eConsult system and to indicate key considerations for system improvement. Methods: This cross-sectional study was conducted at a specialized pediatric acute care hospital in Ottawa, Ontario. Secondary data were obtained over a 2-year period during the COVID-19 pandemic (2019-2022). To gain insights and identify areas of improvement related to the factors pertaining to referrals and eConsults at the process and system levels, quality improvement (QI) methodologies were employed. Descriptive statistics provide a summary of the trends and characteristics of referrals and the utilization of eConsult. Results: Among the 113,790 referrals received, 31,430 were denied. Most common reasons for referral denial were other/null (e.g., unspecified) (29.3%), inappropriate referrals (12.6%), and duplicate referrals (12.4%). Four clinics (e.g., endocrinology, cardiology, neurology, and neurosurgery) reported a total of 277 eConsults, with endocrinology accounting for 95.0% of all eConsults. QI findings revealed the need for standardized workflows among specialties and ensuring that eConsult options are accessible and integrated within the electronic medical record (EMR). Conclusions: Refining the pediatric referral management process and optimizing eConsult through existing clinical systems have the potential to improve the timeliness and quality of specialty care. The results inform future research initiatives targeting improved access to pediatric specialty care and serve as a benchmark for hospitals utilizing EMRs and eConsult.

Increased rate of out-of-network surgeon selection for hip arthroscopy compared to more common orthopedic sports procedures

BackgroundDemand for hip arthroscopy (HA) has increased, but shortfalls in HA training may create disparities in care access. This analysis aimed to (1) compare out-of-network (OON) surgeon utilization for HA with that of more common orthopedics sports procedures, including rotator cuff repair (RCR), partial meniscectomy (PM), and anterior cruciate ligament reconstruction (ACLR), (2) compare the HA OON surgeon rate with another less commonly performed procedure, meniscus allograft transplant (MAT), and (3) analyze trends and predictors of OON surgeon utilization. MethodsThe 2013–2017 IBM MarketScan database identified patients under 65 who underwent HA, RCR, PM, ACLR, or MAT. Demographic differences were determined using standardized differences. Cochran-Armitage tests analyzed trends in OON surgeon utilization. Multivariable logistic regression identified predictors of OON surgeon utilization. Statistical significance was set to p < 0.05 and significant standardized differences were >0.1. Results410,487 patients were identified, of which 12,636 patients underwent HA, 87,607 RCR, 233,241 PM, 76,700 ACLR, and 303 MAT. OON surgeon utilization increased for HA, rising from 7.98 % in 2013 to 9.37 % in 2017 (p = 0.026). Compared to RCR, PM, and ACLR, HA was associated with higher likelihood of OON surgeon utilization. Usage of ambulatory surgery centers (ASCs) was predictive of higher OON surgeon rates along with procedure year, insurance plan type, and geographic region. HA performed in an ASC was 13 % less likely to have an OON surgeon (p = 0.047). ConclusionOON surgeon utilization generally declined but increased for HA. HA was a predictor of OON surgeon status, possibly because HA is a technically complicated procedure with fewer trained in-network providers. Other predictors of OON surgeon status included ASC usage, PPO/EPO plan type, and Northeast geographic region. There is a need to improve access to experienced HA providers—perhaps with prioritization of HA training in residency and fellowship programs—in order to address rising OON surgeon utilization.

Epidemiology of facial skin cancers managed in a French ambulatory surgical center

IntroductionApproximately 80,000 cases of skin cancer are diagnosed annually in France. The management of these cancers can occur in both university hospital centers and ambulatory surgery centers. Limited data exist regarding the epidemiology of cutaneous cancers treated through ambulatory surgery centers. The objective of our study is to describe the epidemiological characteristics of cutaneous cancers managed in a tertiary ambulatory surgery center. MethodsThis is a retrospective, single-center observational study. The included patients were those who underwent surgical excision of one or more skin cancers within the maxillofacial department of a tertiary ambulatory surgery center. Clinical, therapeutic, histopathological, and follow-up data (additional surgery if margins were not clear, progression, recurrence, second cancer…) were collected. ResultsAmong the n = 1931 patients operated for a head and neck skin tumor from September 2018 to July 2022, n = 426 (22 %) were diagnosed with cancer upon histological analysis. The median age was 76 years (31–100), with a male-to-female ratio of 1/1. The most frequent locations were the nose (23 %) and cheek (20 %). Ten percent of patients had dual-site skin cancer at initial diagnosis. The most common histological types were basal cell carcinoma (77 %) and squamous cell carcinoma (18 %). Surgical treatment primarily consisted of "excision-reconstruction with local flap" (51 %) or "excision-suture" (34 %). Resection margins were mostly clear (65 %), and only six patients (2 %) experienced local recurrence or progression during follow-up. ConclusionsSkin cancers are prevalent in ambulatory practice. Surgical treatment allows for effective control of the cancer. Photoprotection, particularly in immunocompromised patients, remains crucial for prevention.

Advancements in Performance of Percutaneous Nephrolithotomy in Ambulatory Surgery Centers: Outcomes and Lessons From 1250+ Cases

ObjectiveTo evaluate the safety and efficacy of routine ambulatory percutaneous nephrolithotomy in a freestanding ambulatory surgical center. MethodsPatients were treated between 2015-2022 by one of three experienced endourologists in Maryland. The surgery center is free-standing, with the nearest hospital approximately 10 minutes away. Patient characteristics and surgical datapoints, including need for transfer, were gathered prospectively at the time of surgery. Subset analyses were performed in patients with staghorn calculi or elevated body mass index, as they represent higher risk populations. ResultsA total of 1267 patients underwent ambulatory percutaneous nephrolithotomy with a median stone diameter of 32mm. The average recovery time was 87 minutes, with 1.7% of patients requiring transfer to the hospital, generally for postoperative hypotension or inadequate pain control. 166 patients with body mass index >40 were safely treated, with no significant difference in transfer rate (p=0.5). 2.8% of patients had a complication, with the majority being Clavien-Dindo grade I or II. 88 patients with staghorn calculi were treated, with a 6% transfer rate. Staghorn calculi were the only factor found on multivariable analysis to be a significant predictor of transfer (OR 3.56 (1.17-10.82) p<.05). ConclusionsAmbulatory percutaneous nephrolithotomy may safely be performed in a surgery center in most patients. These outcomes reflect the real-world experience of high-volume surgeons and demonstrate a multi-year paradigm shift in percutaneous nephrolithotomy from an inpatient procedure to an outpatient procedure in a surgery center.

Comparison of Minimally Invasive Procedures for Benign Prostatic Hyperplasia: A Cost-effectiveness Analysis.

Background Benign prostatic hyperplasia (BPH) is a disease that affects millions of U.S. men and is costly to treat. Purpose To compare the cost-effectiveness of four minimally invasive therapies (MITs) and medical management for the treatment of BPH. Materials and Methods A cost-effectiveness analysis from a payer's perspective with Markov modeling was performed, comparing prostatic artery embolization (PAE), prostatic urethral lift, aquablation, water vapor thermal therapy, and medical management for BPH spanning a time horizon of 5 years. The model incorporated the probability of procedural complications and recurrent symptoms necessitating retreatment, which were extracted from published studies with long-term follow-up. Costs were based on Medicare reimbursements using CPT codes for ambulatory surgery centers. Outcomes were measured using the quality-adjusted life year (QALY), incorporating both life quality and expectancy. Statistical analyses included a base case calculation (using the most probable value of each parameter) and probabilistic and deterministic sensitivity analyses. Results In the base case calculation, outcomes for the strategies were comparable, with a difference of 0.030 QALY (11 days of life in perfect health) between the most (PAE) and least (medical management) effective strategies. PAE was the most cost-effective strategy relative to medical management, with an incremental cost-effectiveness ratio of $64 842 per QALY. Probabilistic sensitivity analysis showed PAE was more cost-effective compared with prostatic urethral lift, aquablation, water vapor therapy, and medical management in pairwise comparisons. In sensitivity analysis of retreatment risk, PAE remained the most cost-effective strategy until its repeat treatment rates exceeded 2.30% per 6 months, at which point water vapor therapy became the optimal choice. PAE was the most cost-effective procedure when its procedural cost was lower than $4755. Aquablation and prostatic urethral lift became more cost-effective when their procedural costs were lower than $3015 and $1097, respectively. Conclusion This modeling-based study showed that PAE appears to be a cost-effective modality among medical management and MITs for patients with BPH, with comparable outcomes to prostatic urethral lift, water vapor therapy, and aquablation at a lower expected cost. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Gemmete in this issue.

Modern robotics platform associated with reduced 90-day complications in hospital setting

BACKGROUND: Early complications in total knee arthroplasty (TKA) associated with modern robotics platforms integrated with digital balancing technology have not been investigated. OBJECTIVE: The objective was to compare 90-day complication rates between a manual technique and a modern robotic-assisted ligament balancing TKA platform. METHODS: 895 primary TKA procedures from a single surgeon were retrospectively reviewed (614 manual TKA, 281 using a modern robotics platform with an integrated digitally controlled ligament balancing device). Post-operative complications within the 90-day episode of care were recorded by the Michigan Arthroplasty Registry Collaborative Quality Initiative. Differences in complication rates between techniques were further divided into inpatient hospital, outpatient hospital, and ambulatory surgery center (ASC) cohorts. RESULTS: In the pooled hospital cohort and inpatient hospital cohort, ‘Return to OR’ was significantly lower for the robotic assisted group (1.3% vs 5.2% and 0% vs 4.9%, respectively, p&lt; 0.0370). Specifically, the need for manipulation under anesthesia (MUA) was reduced for the robotics group (0.0% vs 2.5%, p= 0.0352). No differences in overall complication rate or cause of complication was found between manual and robotics cases for the hospital outpatient and ASC cohorts (p⩾ 0.68). CONCLUSION: Within the hospital setting, robotic assisted ligament balancing technology was associated with reduced 90-day postoperative complications for ‘Return to OR’ and MUA.

Increasing the Volume of Outpatient Total Joint Arthroplasty Procedures: An Evaluation of a Novel Rapid Recovery Pathway Program Within an Academic Medical Center.

There has been a national trend toward shifting joint arthroplasty procedures to the outpatient setting. These cases are often performed in freestanding ambulatory surgery centers (ASCs), which are often not accessible to surgeons within academic practices. We sought to investigate a novel rapid recovery program used to transition arthroplasty patients to an outpatient-based care system within an academic medical center. All patients undergoing hip or knee arthroplasty between November 2019 and April 2021 were retrospectively evaluated for their eligibility for a rapid recovery pathway through the Extended Stay Unit (ESU) based on clinical and social criteria. Once admitted, patients were evaluated for whether they were discharged from the unit or if hospital admission was necessary. Out of the 444 patients deemed candidates for the rapid recovery program, 188 patients were admitted to the ESU (42.3%); 18 (9.6%) required inpatient hospital admission, with the majority of these due to failing physical therapy (16; 88.9%). Of the ESU patients who were successfully discharged home, 55 (32.4%) were discharged on postoperative day (POD) 0 and 115 (67.6%) on POD 1 (<23 hours). As total joint arthroplasties shift toward the outpatient setting, surgeons in academic institutions must employ strategies to increase their volume of patient candidates for outpatient procedures. Our retrospective study of prospectively collected data suggests the feasibility of creating a separate rapid recovery unit within the hospital that can be an effective method by which to eventually transition to the ASC setting.

Joint Replacement Technology in the Ambulatory Surgery Center: Current and Future Applications.

Total joint replacement (TJR) surgery in the ambulatory surgery centers (ASCs) has grown significantly over the past several years, along with the ability to improve the value of care. Standardization of high-quality, perioperative care is pivotal to the success of a TJR ASC program. As surgeons are experiencing increasing overhead with decreasing reimbursement, technology integration can provide major advantages. In this article, we will therefore highlight several examples of technologies that are changing the field and improving care in the preoperative, intraoperative, and postoperative settings.

Oral Sedation Anesthesia Protocol for In-Office Oculoplastic Surgery.

To present an oral anesthesia protocol for in-office oculoplastic surgery and to compare safety outcomes and patient and physician experiences to ambulatory surgery center (ASC)-based surgery with intravenous sedation or general anesthesia. A prospective study was performed on consecutive patients undergoing surgery at an oculofacial plastic surgery practice. Surgery was performed in an in-office setting using our standardized oral sedation protocol or at an ASC with intravenous sedation or general anesthesia. Preoperative and postoperative surveys were conducted by patients and physicians to compare surgical experience, safety, and efficacy of our oral sedation protocol for in-office surgery in the ASC setting. Two hundred and fifty-three patients (167 in-office and 86 at ASC) underwent surgery between March and November 2022. There was no significant difference in how patients or physicians rated their experience between the 2 locations. A significantly higher proportion of ASC patients would have rather had surgery in-office (34.9% vs. 19.2%; p = 0.006). A significantly higher number of physicians in the office setting would have rather performed surgery at the ASC than the reverse (12.7% vs. 2.3%, respectfully; p = 0.007). There were no safety complications reported in either setting. Within our patient cohort, the presented oral sedation protocol provided safe and effective anesthesia for in-office oculoplastic surgery that is comparable to an ASC.

Outpatient Spine Procedures in Poland: Clinical Outcomes, Safety, Complications, and Technical Insights into an Ambulatory Spine Surgery Center.

This study evaluated the safety and efficacy of spine procedures performed in an ambulatory spine surgery unit in Poland. We conducted a retrospective analysis of 318 patients who underwent ambulatory spine surgery between 2018 and 2021, with procedures including microdiscectomy (MLD), anterior cervical discectomy and fusion (ACDF), endoscopic interbody fusion (endoLIF), posterior endoscopic cervical discectomy (PECD), interlaminar endoscopic lumbar discectomy IELD, and transforaminal endoscopic lumbar discectomy (TELD). Patient data were analyzed for pre-operative and post-operative visual analog scale (VAS) scores. The findings indicated that outpatient techniques were safe and effective, with a 2.83% complication rate. All procedures significantly improved VAS scores under short-term observation, and core outcome measurement index (COMI) scores under long-term observation. Ambulatory spine surgery represents a relatively new approach in Poland, with only a select few centers currently offering this type of service. Outpatient spine surgery is a safe, effective, and cost-effective option for patients requiring basic spine surgeries.

Impact of Ketorolac on Reoperation for Hemorrhage After Pediatric Tonsillectomy: A Single-Center Retrospective Propensity-Matched Study.

To determine if perioperative ketorolac is associated with an increased rate of reoperation for hemorrhage after pediatric tonsillectomy at 30 days and 48hours. Single-center retrospective propensity-matched study. Quaternary pediatric hospital and ambulatory surgery center. Patients less than 18 years old undergoing tonsillectomy or adenotonsillectomy between January 1, 2015 and October 1, 2020 were included. Hemorrhage rates between exposed (K+) and unexposed (K-) patients were calculated for the total cohort and a 1:1 propensity-matched cohort. Additional analyses included: multivariable logistic regression, subgroup analysis of ASA 1 and 2 patients, subgroup analysis comparing children with teenagers. There were 5873 patients (42.1% K+) in the full cohort and 4694 patients in the propensity-matched cohort. Reoperation for hemorrhage within 30 days occurred in 1.9% of K+ patients and 1.6% of K- patients (P = 0.455) in the full cohort and 1.9% of K+ patients and 1.7% of K- patients (odds ratio [OR] 1.10, 95% confidence interval [CI] 0.72-1.69, P = 0.662) in the propensity-matched cohort. Reoperation within 48 hours occurred in 0.65% of K+ patients and 0.53% of K- patients (P = 0.679) in the full cohort and 0.68% of K+ patients and 0.51% of K- patients (OR 1.33, 95% CI 0.63-2.81, P = 0.451) in the propensity-matched cohort. There was no association between perioperative ketorolac administration and reoperation for hemorrhage in any of the other analyses. Ketorolac at end of surgery should be considered as part of the nonopioid analgesic regimen for pediatric tonsillectomy.

Emergency Department Visit Rates After Ambulatory Surgery

This cohort study compares the rates of emergency department visits after cholecystectomy, transurethral resection of the prostate, and knee arthroplasty at freestanding ambulatory surgery centers vs hospital-owned surgery centers.

Ambulatory Surgery Centers Reduce Patient Out-of-Pocket Expenditures for Isolated Arthroscopic Rotator Cuff Repair, but Patient Out-of-Pocket Expenditures Are Increasing at a Faster Rate Than Total Healthcare Utilization Reimbursement From Payers

To categorize and trend annual out-of-pocket expenditures for arthroscopic rotator cuff repair (RCR) patients relative to total healthcare utilization (THU) reimbursement and compare drivers of patient out-of-pocket expenditures (POPE) in a granular fashion via analyses by insurance type and surgical setting. Patients who underwent outpatient arthroscopic RCR in the United States from 2013 to 2018 were identified from the IBM MarketScan Database. Primary outcome variables were total POPE and THU reimbursement, which were calculated for all claims in the 9-month perioperative period. Trends in outcome variables over time and differences across insurance types were analyzed. Multivariable analysis was performed to investigate drivers of POPE. A total of 52,330 arthroscopic RCR patients were identified. Between 2013 and 2018, median POPE increased by 47.5% ($917 to $1,353), and median THU increased by 9.3% ($11,964 to $13,076). Patients with high deductible insurance plans paid $1,910 toward their THU, 52.5% more than patients with preferred provider plans ($1,253, P= .001) and 280.5% more than patients with managed care plans ($502, P= .001). All components of POPE increased over the study period, with the largest observed increase being POPE for the immediate procedure (P= .001). On multivariable analysis, out-of-network facility, out-of-network surgeon, and high-deductible insurance most significantly increased POPE. POPE for arthroscopic RCR increased at a higher rate than THU over the study period, demonstrating that patients are paying an increasing proportion of RCR costs. A large percentage of this increase comes from increasing POPE for the immediate procedure. Out-of-network facility status increased POPE 3 times more than out-of-network surgeon status, and future cost-optimization strategies should focus on facility-specific reimbursements in particular. Last, ambulatory surgery centers (ASCs) significantly reduced POPE, so performing arthroscopic RCRs at ASCs is beneficial to cost-minimization efforts. This study highlights that although payers have increased reimbursement for RCR, patient out-of-pocket expenditures have increased at a much higher rate. Furthermore, this study elucidates trends in and drivers of patient out-of-pocket payments for RCR, providing evidence for development of cost-optimization strategies and counseling of patients undergoing RCR.

Minority and Lower Socioeconomic Status Patients Receive Ankle Fracture Care at Higher Cost Sites

Category: Ankle; Trauma Introduction/ Purpose: Socioeconomic disparities exist in the delivery of orthopedic care. Inequitable outcomes based on socioeconomic status (SES), including income, race, and geography, have been studied in association with outcomes following lower extremity trauma care. As orthopedic surgical care shifts increasingly towards providing care in hospital outpatient departments (HOPD) and freestanding ambulatory surgery centers (ASC), there is an opportunity to address socioeconomic disparities. We aimed to assess the association between patient SES and the outpatient facility type (HOPD versus ASC) where ankle fracture care was performed. We hypothesize: (1) White patients are more likely to receive care at ASCs, (2) Minority and lower income patients are more likely to receive care at HOPDs, and (3) Total charges for care are higher for minority and lower income patients. Methods: Data in patients ≥16 years old was sourced from the State Inpatient Database and Healthcare Utilization Project State Ambulatory Surgery Database (SASD) (for Florida, North Carolina, and Wisconsin) from 2016-2019. These 3 states were selected because their SASDs include a variable defining the location of service as a hospital outpatient department (HOPD) or ASC. Cases were identified using CPT codes converted to ICD-10 procedural codes for ankle fracture open reduction and internal fixation (ORIF). 85,749 cases were included: 50,411 (59%) inpatient, 28,536 (33%) HOPD, and 6,802 (8%) ASC, representing approximately 20% of inpatient and 11.5% of outpatient cases performed in the United States. Patient and facility characteristics were abstracted. Appropriate statistical analyses were conducted to describe and compare differences between facility type and patient characteristics. Results: Significant race and income disparities exist in outpatient ankle fracture care by facility type. Most patients receiving care were White (71%). Of the patients who received care at an HOPD, 32% were Black compared to 6% at ASCs (OR 0.795, CI 0.728-0.869). Of patients receiving care at an HOPD, 27% were other minorities compared to 9% at ASC (OR 1.213, CI 1.213- 1.309). More patients at HOPDs were in the lowest income level (26%) compared to ASC (18%). Factors found to associated with higher charges for surgery included patient being of minority race, patient of lower income level, and surgery performed at HOPD versus ASC. Conclusion: Ankle fractures treated at ASCs were more likely to be White and of higher income. These socioeconomic and racial/ethnic disparities are also associated with receiving care with higher total charges. These data indicate inequitable access to ankle fracture care performed at ASC facilities. More attention to social determinants of health is critical in the context of ankle fracture care to address potential inequitable outcomes and higher cost of care.

Surgical Setting in Achilles Tendon Repair: How Does It Relate to Costs and Complications?

Primary Achilles tendon repair (ATR) can be performed in ambulatory surgery centers (ASCs) or hospitals. We compared costs and complication rates of ATR performed in these settings. We retrospectively queried the electronic medical record of our academic health system and identified 97 adults who underwent primary ATR from 2015 to 2021. Variables were compared between patients treated at ASCs vs those treated in hospitals. We compared continuous variables with Wilcoxon rank-sum tests and categorical variables with χ2 tests. We used an α of 0.05. Multivariable logistic regression was performed to determine associations between surgical setting and costs. Linear regression was performed between each charge subtype and total cost to identify which charge subtypes were most associated with total cost. Patients who underwent ATR in hospitals had a higher rate of unanticipated postoperative hospital admission (13%) than those treated in ASCs (0%) (P = .01). We found no differences with regard to postoperative complications, emergency department visits, readmission, rerupture, reoperation/revision, or death. Patients treated in hospitals had a higher mean (±SD) implant cost ($664 ± $810) than those treated in ASCs ($175 ± $585) (P < .01). We found no differences between settings with regard to total cost, supply costs, operating room charges, or anesthesia charges. Higher implant cost was associated with hospital setting (odds ratio = 16 [95% CI: 1.7-157]) and body mass index > 25 (odds ratio = 1.2 [95% CI: 1.0-1.5]). Operating room costs were strongly correlated with total costs (R2 = .94). The overall cost and complication rate of ATRs were not significantly different between ASCs and hospitals. ATRs performed in hospitals had higher implant costs and higher rates of postoperative admission than those performed in ASCs. Level III, retrospective comparative study.

The Differential Effect of COVID on Total Joint Arthroplasty Between Hospital and Ambulatory Surgery Centers/Hospital Outpatient Departments: A Michigan Arthroplasty Registry Collaborative Quality Initiative Analysis.

Coronavirus disease (COVID) created unprecedented challenges, especially for high-volume elective subspecialties like total joint arthroplasty. Limited inpatient capacity and resource conservation led to new outpatient selection criteria and site of service changes. As a Michigan Arthroplasty Registry Quality Collaborative Initiative quality project, demographic changes, complications, and differential effects on inpatient vs outpatient centers pre- and post-COVID were analyzed. The registry identified all total joint arthroplasty at hospitals and ASCs/HOPDs between 07/2019-12/2019 and 07/2020-12/2020. These intervals represented pre-COVID and post-COVID elective surgery shutdowns. Case volumes, demographics, and 90-day complications were compared. Comparing 2020 to 2019, hospital volumes decreased (-9% total hip arthroplasty [THA],-17% total knee arthroplasty [TKA]), and ambulatory surgery center (ASC)/hospital outpatient department (HOPD) increased (+84% THA,+125% TKA). Entering 2020, ASC/HOPD patients were older (P= .0031, P < .0001: THA, TKA), had more American Society of Anesthesiologists score 3-4 (P= .0105, P= .0021), fewer attended joint class (P < .0001, P < .0001), and more hips were women (P= .023). Hospital patients had higher preoperative pain scores (P= .0117, P < .0001; THA, TKA), less joint education attendance (P < .0001, P < .0001), younger TKAs (P= .0169), and more American Society of Anesthesiologists score 3-4 (0.0009). After propensity matching, there were no significant differences between site of service for 90-day fractures, deep vein thromboses or pulmonary embolisms, infection, or hip dislocations. Hospital THAs had higher readmissions (P= .0003) and TKAs had higher 30-day emergency department visits (P= .005). ASC/HOPD patients were prescribed higher oral morphine equivalents (P < .0001, P < .0001; THA, TKA). COVID's elective surgery shutdown caused a dramatic site of service shift. Traditional preoperative education was negatively impacted, and older and sicker patients became outpatients. But short-term complications were not increased in ASCs/HOPDs. These site of service and associated patient demographic changes may be safely sustained.