Ambulatory Surgical Center Setting Research Articles

Business and Corporate Models for Interventional Radiology in the Office Based Lab and Ambulatory Surgical Center Setting

The landscape of healthcare is shifting towards outpatient settings such as Office-Based Labs (OBLs) and Ambulatory Surgery Centers (ASCs). This transition, driven by the Centers for Medicare & Medicaid Services (CMS), presents various business and corporate models for interventional radiologists seeking to practice outside traditional hospital environments. The role of private equity and management services in facilitating these transitions is highlighted, offering opportunities for growth, efficiency, and enhanced control over practice operations. The document also discusses the financial aspects of establishing an OBL or ASC, the benefits of outpatient procedures, and the adaptability of private equity deals to the specific needs of medical practices. It concludes by emphasizing the potential for long-term wealth creation and the adaptability of these models to individual physician needs.

Pixee knee+ augmented reality assisted navigation for total knee arthroplasty in an ambulatory surgical center

Total knee arthroplasty (TKA) requires precise alignment for optimal post-operative outcomes and prosthesis longevity. Recently, augmented reality (AR) has emerged as a promising technology in surgical procedures, including TKA. This case series evaluates the feasibility and accuracy of the knee+ augmented reality-assisted navigation (ARAN) system by Pixee Medical in an ambulatory surgical center (ASC) setting. Our study involved 17 consecutive TKA patients performed with the knee+ ARAN system at an ASC from August 2022 to October 2022. Demographic data, including sex, age, ASA score, height, weight, and BMI, were recorded. Postoperative measurements of the mechanical distal femoral angle (MDFA), mechanical distal tibial angle (MDTA), posterior tibial slope (PTS), femoral-tibial angle (FTA), and posterior femoral flexion (PFF) were compared to the ideal intraoperative angles. Outliers were defined as deviations greater than 3° from the planned angles. In this study, 15 out of 17 TKAs utilizing the Pixee knee+ ARAN system were analyzed. All mean post-operative radiographic measurements were within clinically acceptable ranges. The study also found that surgeries using the knee+ system had a slightly longer incision-to-closing time relative to the control group of patients undergoing normal TKA. Our results indicate clinically acceptable accuracy and precision in alignment with the knee+ ARAN system, albeit with a slight increase in surgery duration. This is the first study evaluating the knee+ ARAN system in an ASC setting indicates its suitability for outpatient centers, highlighting its precision, portability, and cost-effectiveness. Larger studies utilizing outcome measures can further assess the system’s advantages and disadvantages.

Early Real-World Physician Experience with an Intracanalicular Dexamethasone Insert.

PurposeTo describe the early real-world experience of physicians with an intracanalicular dexamethasone insert (DEX) in patients undergoing cataract surgery and to capture the clinical impact of adopting this therapy.Patients and Methods23 United States sites including Ambulatory Surgical Center Setting (ASC) and Outpatient Clinical settings. Respondents were physicians who had early experience with DEX in cataract surgery patients. This was a Phase 4 experiential cross-sectional survey study comprised of 3 sequential online physician surveys. Descriptive statistics summarized the surveys’ responses to determine the early impressions of the respondents.ResultsForty-two physicians completed surveys. On average, physicians reported feeling comfortable administering DEX after placing 3 inserts (mean 2.7; standard deviation 1.9). Most physicians (92%) were satisfied with DEX, and all physicians (100%) reported that DEX improved patient compliance. Most physicians (62.5%) indicated they would highly prefer DEX over traditional steroid eyedrops for the management of post-surgical inflammation and pain.ConclusionThe surveys exploring the early use of DEX suggest that DEX is a clinically effective treatment with a rapid initial learning curve and integrates well into clinical use. Physicians had a very positive early experience with DEX, including comfort with insertion and satisfaction. DEX shows promise as a primary treatment choice of physicians for ocular inflammation and pain following cataract surgery by offering patients a hands-free innovative therapy that delivers a preservative-free steroid to the ocular surface over approximately 30 days.

Spine Surgery Complications in the Ambulatory Surgical Center Setting: Systematic Review.

This was a systematic review study. This study aims to review current literature to determine the rates of complications in relation to spine surgery in ambulatory surgery centers (ASC). Recent improvements in anesthesia, surgical techniques, and technological advances have facilitated a rise in the use of ASC. Despite the benefits and lower costs associated with ASCs, there is inconsistent reporting of complication rates. This systematic review was completed utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Pertinent studies were identified through Embase and PubMed databases using the search string ((("ambulatory surgery center") AND "spine surgery") AND "complications"). Articles were excluded if they did not report outpatient surgery in an ASC, did not define complications, were in a language other than English, were non-human studies, or if the articles were classified as reviews, book chapters, single case reports, or small case series (≤10 patients). The primary outcome was the frequency of complications with respect to various categories. Our query identified 150 articles. After filtering relevance by title, abstract, and full text, 22 articles were included. After accounting for 2 studies that were conducted on the same study sample, a total of 11,245 patients were analyzed in this study. The most recent study reported results from May 2019. While 5 studies did not list their surgical technique, studies reported techniques including open (6), minimally invasive surgery (2), endoscopic (4), microsurgery (1), and combined techniques (4). The following rates of complications were determined: cardiac 0.29% (3/1027), vascular 0.25% (18/7116), pulmonary 0.60% (11/1839), gastrointestinal 1.12% (2/179), musculoskeletal/spine/operative 0.59% (24/4053), urologic 0.80% (2/250), transient neurological 0.67% (31/4616), persistent neurological 0.61% (9/1479), pain related 0.57% (20/3479), and wound site 0.68% (28/4092). After literature review, this is the first study to comprehensively analyze the current state of literature reporting on the complication profile of all ASC spine surgery procedures. The most common complications were gastrointestinal (1.12%) and the most infrequent were vascular (0.25%). Case reports varied significantly with regard to the type and rate of complications reported. This study provides complication profiles to assist surgeons in counseling patients on the most realistic expectations.

Multimodal Analgesic Management for Cervical Spine Surgery in the Ambulatory Setting.

Patient selection and analgesic techniques, such as the multimodal analgesic (MMA) protocol, aid in ambulatory surgical center (ASC) cervical spine surgery. The purpose of this case series is to characterize patients undergoing anterior cervical discectomy and fusion (ACDF) and total cervical disc replacement (CDR) in an ASC with an enhanced MMA protocol. A prospectively maintained registry was retrospectively reviewed for cervical surgeries between May 2013 and August 2019. Inclusion criteria included ASC patients who underwent single-level or multilevel CDR or ACDF using an MMA protocol. Baseline, intraoperative, and postoperative characteristics were recorded, including length of stay, visual analog scale pain scores, neck disability index, complications, and narcotics administered. A total of 178 patients met inclusion criteria with 125 single-level, 52 two-level, and 1 three-level procedure. Of those patients, 127 underwent ACDF and 51 underwent CDR. The longest procedure was 95 minutes and the mean length of stay was 6.1 hours, with 2 patients requiring hospital admission. All other patients were discharged within 10 hours. One of the admitted patients experienced a postoperative seizure that was later determined to be secondary to drug use and serotonin syndrome. The second patient developed an anterior cervical hematoma 5 hours postoperatively, which was immediately evacuated. The patient was admitted for observation and discharged the next day. In our study, patients experienced considerable improvement in disability scores, with a low likelihood of postoperative complications. A safe and effective MMA protocol may help facilitate anterior cervical surgery in the outpatient setting. 3. Transitioning anterior cervical discectomy and fusions to the ASC requires an appropriate MMA protocol. Our findings reveal that an enhanced MMA protocol will help improve disability scores while keeping the likelihood of postoperative complications low. This supports the ASC setting for cervical spine procedures in appropriate patient populations.

Compensation Rates for Otolaryngologic Procedures Under the Medicare Physician Fee Schedule in 2018.

Medicare reimbursement for physician work depends on the estimated time and intensity - which encompasses technical skill, cognitive load, and stress - required to perform services. The Centers for Medicare and Medicaid Services (CMS) quantitatively expresses intensity estimates as compensation rates per unit time. This study aimed to characterize compensation rates under the Medicare Physician Fee Schedule (PFS) for operative procedures commonly performed by otolaryngologists. This study was a retrospective, cross-sectional analysis. This study was a retrospective, cross-sectional analysis of fiscal year 2018 PFS specifications and publicly available Medicare Part B utilization data for the top 100 highest-volume procedures furnished by otolaryngologists to Medicare beneficiaries in inpatient and ambulatory surgical center (ASC) settings between January 1, 2018, and December 31, 2018. Co-primary outcomes were the estimated 1) total compensation rate ($/min) and 2) intraservice (i.e., "skin-to-skin" time) compensation rate ($/min) for each included procedure. The analytic sample included 147 unique procedure types (settings non-mutually exclusive): 82 inpatient procedure types (n = 33,907 procedures) and 95 ASC procedure types (n = 34,765 procedures). In the inpatient setting, median total compensation rate and intraservice compensation rates were $1.50/min (interquartile range [IQR]: $1.19/min-$1.65/min) and $2.27/min (IQR: $1.69/min-$2.68/min), respectively. In the ASC setting, median total compensation rate and intraservice compensation rates were $1.48/min (interquartile range [IQR]: $1.27/min-$1.77/min) and $2.39/min (IQR: $1.82/min-$2.91/min), respectively. At the service line level, volume-weighted total (inpatient: $1.91/min, ASC: $1.90/min) and intraservice (inpatient: $3.84/min, ASC: $3.37/min) compensation rates were highest for rhinologic procedures. Compensation rates under the Medicare PFS varied widely for operative procedures commonly performed by otolaryngologists. NA Laryngoscope, 131:E1785-E1791, 2021.

Transcervical Fibroid Ablation (TFA) in an Ambulatory Surgical Center Setting: Utility during the COVID-19 Pandemic

Study ObjectiveTo describe the experience of TFA with the Sonata® system in the ambulatory surgicenter (ASC) setting, relative to current recommendations by medical societies for elective procedures during the COVID-19 pandemic.DesignProspective, longitudinal, multicenter controlled trial.Setting22 clinical sites in the US and Mexico.Patients or Participants147 premenopausal women between the ages of 25 and 50 with heavy menstrual bleeding secondary to nonpedunculated fibroids.InterventionsTranscervical, intrauterine ultrasound-guided radiofrequency ablation with the Sonata system. Pain scores were recorded after each procedure using a scale from 0-10. Length of stay (LOS) was measured from procedure start through discharge.Measurements and Main ResultsOf 147 treated patients, 49 were treated in an ASC setting and 98 were treated in other outpatient settings. Fifty-five percent of patients treated in an ASC had general anesthesia and 45% had conscious sedation vs 48% and 52%, respectively for non-ASC population. Average number of fibroids treated per patient was 3.2±2.0 and 2.9±2.1 in ASC and non-ASC, respectively. Mean LOS was 2.1±0.9 hours vs. 2.8±1.3 hours for ASC and non-ASC patients, respectively. Mean procedure pain scores were 0±0% for the ASC patients (0.4±1.1 for non-ASC patients). Mean return to normal activity for patients treated in ASC was 1.7±1.4 days (2.4±2.5 for non-ASC patients). Mean 12-month improvements in SSS and HRQL scores were -34.8±23.9 and 48.6±26.2 points, respectively, in ASC patients (-30.4±19.3 and 41.0±23.0, respectively, in non-ASC patients).ConclusionCurrent surgical guidance during the COVID-19 pandemic encourages avoidance of endotracheal intubation when appropriate and minimizing exposure time for patients and staff. Transcervical Fibroid Ablation with the Sonata system is performed without pneumoperitoneum or a requirement for intubation, providing short LOS, minimal pain scores and improved outcomes while potentially reducing risk to healthcare personnel and patients alike.

62. Multimodal analgesic management for lumbar decompression surgery in the ambulatory setting clinical case series and review of the literature

BACKGROUND CONTEXT Patient selection and new anesthetic techniques, such as the refined multimodal analgesic (MMA) protocol, aide in performing lumbar decompression surgery procedures in the ambulatory surgical center (ASC) setting. PURPOSE To characterize a case series of patients who underwent lumbar decompression (LD) in the ASC setting with the use of an MMA protocol. STUDY DESIGN/SETTING Retrospective. PATIENT SAMPLE A total of 499 patients who underwent single or multilevel LD. OUTCOME MEASURES Visual analog scale (VAS) pain, length of stay, oral morphine equivalents (OME). METHODS A prospective surgical registry was retrospectively assessed for patients who were eligible for this study. The senior author performed all procedures and had extensive experience operating in an ASC. Observation in excess of 23 hours was not permitted at the ASC. All patients were required to be discharged the same day. Consecutive patients were identified who underwent single or multilevel LD in the ambulatory setting between May 2013 until August 2019. Procedures were conducted using the aforementioned MMA protocol. Baseline characteristics were recorded including patient demographics such as: age, gender, body mass index (BMI), smoking status, Charlson Comorbidity Index (CCI), American Society of Anesthesiologists (ASA) score, preoperative chronic medical conditions, and spinal diagnoses. Intraoperative characteristics were collected, including operative level, operative location, operative time (time from skin incision to skin closure), and estimated blood loss (EBL). Postoperative characteristics were recorded, including surgery center length-of-stay, patient-reported VAS pain scores prior to discharge, and the quantity of narcotic medications administered to patients prior to discharge were converted into units of oral morphine equivalents (OME) and summed across all types of narcotic medications prescribed. Postoperative complications while in the surgical center were also recorded. RESULTS A total of 499 patients who underwent lumbar decompression procedures were identified between April 2013 and September 2019. Of the total patients, 86.0% (429) underwent a single-level decompression procedure, 13.8% (69) underwent a two-level, and 0.2% (1) underwent a three-level procedure. Of the patients in this study, 83.6% (417) underwent a primary LD and 14.0% (70) underwent a revision decompression. The longest surgical case was 105 minutes with a mean of 44.1±13.3 minutes. The mean length of stay was 2.5±1.1 hours, with the longest was 7.6 hours. All other patients were discharged within 7.6 hours of the procedure end. CONCLUSIONS With the 499 patients in this ASC study on MMA protocol, this is the largest clinical case series focused on lumbar decompression procedures within an ASC requiring no planned 23-hour observation. This study demonstrates the feasibility of performing lumbar decompression surgery in an ASC with proper patient selection, surgical technique and a multimodal analgesia protocol. Postoperative pain was controlled for all patients, and all were discharged from the surgical center on the same day of surgery. Overall, the reduction in VAS and the rapidly treated yet minor postoperative complications suggest that lumbar decompressions can be safely performed in the ASC setting with an MMA protocol. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

49. A systematic review of spine surgery complications in the ambulatory surgical center setting

BACKGROUND CONTEXT In recent years, a combination of improved anesthesia, surgical techniques, and technological advances have facilitated a rise in the use of ambulatory surgery centers (ASC). Despite the lower costs associated with ASCs, improved efficiency, and increased patient satisfaction, there is inconsistent reporting of complication rates. PURPOSE This study aims to review current literature in order to determine the outcomes and complication rates in relation to surgery in ambulatory surgical centers. STUDY DESIGN/SETTING Retrospective. PATIENT SAMPLE One hundred and fifty articles on surgery complications in ambulatory surgical centers. OUTCOME MEASURES Postoperative complications (cardiac, GI, MSK, operative, pain, neurologic, pulmonary, urologic, vascular, and wounds). METHODS This systematic review was completed utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Pertinent studies were identified through Embase and Pubmed databases using the search string (((ambulatory surgery center) AND spine surgery) AND complications). Articles were excluded if they did not report outpatient surgery in an ASC, if they did not define complications in a language other than English, nonhuman studies, or if the articles were classified as reviews, book chapters, single case reports, or small case series (≤10 patients). Comparative studies were only included if they provided the number of both ambulatory and nonambulatory patients. The primary outcome was the frequency of complications with respect to the following categories: cardiac, gastrointestinal, MSK/spine/operative, pain, persistent neurologic, pulmonary, transient neurologic, urologic, vascular, and wound. RESULTS Our query identified 150 articles. After filtering relevance by title, abstract, and full text, 22 articles were included. After accounting for two studies that were conducted on the same study sample, a total of 11,245 patients were analyzed in this study. The most recent study reported results from May 2019. While five studies did not list their surgical technique, reported techniques by each study included open (6), MIS (2), endoscopic (4), microsurgery (1), and combined techniques (4). The following rates of complications were determined: cardiac 2/2168 (0.09%), gastrointestinal 2/1320 (0.15%), MSK/spine/operative 10/8210 (0.12%), pain 10/4634 (0.22%), persistent neurologic 5/3318 (0.15%), pulmonary 1/1839 (0.05%), transient neurologic 11/3821 (0.29%), urologic 2/250 (0.80%), vascular 6/5277 (0.11%), and wound 7/5733 (0.12%). CONCLUSIONS After literature review, this is the first study to comprehensively analyze the current state of literature reporting on the complication profile of all ASC surgery procedures. The most common complications were urologic (0.8%) and the most infrequent were pulmonary (0.05%). Case reports varied significantly with regard to the type and rate of complications reported. Although the patient population undergoing ASC surgery is likely to be screened more rigorously than the inpatient surgery population, this study provides complication profiles to assist surgeons in counseling patients on the most realistic expectations. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Risk Factors for Surgical Site Infections After Orthopaedic Surgery in the Ambulatory Surgical Center Setting.

This study was designed to determine the incidence of surgical site infections (SSIs) after orthopaedic surgery in an ambulatory surgery center (ASC) and to identify patient and surgical risk factors associated with SSI. Patients who underwent orthopaedic surgery at an ASC over a 6.5-year period were reviewed for evidence of SSI. Data on patient and surgical factors were collected, and stepwise multivariate logistic regression determined the risk factors for SSI. The incidence of SSIs was 0.32%. Five independent factors were associated with SSI: anatomic area (odds ratio [OR] = 18.60, 11.24, 6.75, and 4.01 for the hip, foot/ankle, knee/leg, and hand/elbow versus shoulder, respectively), anesthesia type (OR = 4.49 combined general and regional anesthesia versus general anesthesia), age ≥70 (OR = 2.85), diabetes mellitus (OR = 2.27), and tourniquet time (OR = 1.01 per minute tourniquet time). The risk of infection after orthopaedic surgery in ASCs is low, but patient and surgical factors are independently associated with SSIs.

Patient education in an ambulatory surgical center setting

Advancements in surgical technology over the past decade have resulted in the ability to perform complex surgical procedures on the spine with decreased morbidity and advanced recovery. With an increased national focus on decreasing health expenditures, spine surgery has been particularly highlighted as having potential to make significant changes in the current landscape (1). This has resulted in a recent push towards further streamlining various spine procedures in an effort to decrease postoperative pain, minimize narcotic use, promote faster recovery, and decrease complications without compromising the quality of the procedure performed. Minimally invasive techniques have the potential to pave the way for surgeons to execute safe and effective procedures directed at achieving these goals. In partnership with anesthesiologists, the door has been opened for a number of spine surgeries to be performed in an ambulatory surgical center (ASC) setting.

Safe Discharge of Patients From an Ambulatory Care Center After Incidental Durotomy During Minimally Invasive Spine Surgery.

Incidental durotomy is a well-known complication of spinal surgery that may occur occasionally. Increasingly, minimally invasive techniques are being used for spinal decompressions in an ambulatory surgical center (ASC) setting. The management of this complication in an ASC setting has not been reported. A total of 832 consecutive minimally invasive decompressive spinal surgeries were performed by a single surgeon in an ASC during the course of 1 year. Incidental durotomies with cerebrospinal fluid leakage were repaired and patients were discharged to home. Patients with a watertight suture dural repair did not receive any modifications to the usual discharge activities allowed. All other patients were treated with bed rest overnight and head of bed restrictions. A protocol for close patient follow-up after discharge was followed. The complications were collected prospectively and analyzed retrospectively. There were 30 incidental durotomies (3.6%), with all occurring in the lumbar spine. Suture repair was accomplished in 28 patients (93%). Patch repair was performed in 2 patients (7%). All patients were discharged to home from the ASC. There were 2 short-term complications noted after discharge. The patient safety protocols in place identified the complications and allowed timely interventions. Incidental durotomy occurring during minimally invasive spinal decompressive surgery is an occasional event. Suture repair of the laceration is feasible in most instances. Lumbar spine patients may be safely discharged to home from the ASC. Patients can be stratified into those with, or without, a watertight suture dural closure. Those with such a closure, who are without symptoms of intracranial hypotension, do not require modification of their activities. A short period of bedrest with head of bed modification successfully treated the remainder. Hospitalization or routine prolonged bed rest is not necessary. Protocols must be put in place to identify and timely manage potentially serious sequelae.

Wednesday, September 26, 2018 1:00 PM – 2:00 PM Navigation and Intraoperative Monitoring: 49. Novel technology for C-arm based pedicle navigation

Wednesday, September 26, 2018 1:00 PM – 2:00 PM Navigation and Intraoperative Monitoring: 49. Novel technology for C-arm based pedicle navigation

Interventional Techniques in Ambulatory Surgical Centers: A Look at the New Payment System

There has been an explosive increase in procedures performed in surgery centers, with approximately 4,700 Medicare-certified surgery centers in the United States. Total ambulatory surgical center (ASC) payments have increased substantially: $1 billion in 1996, and $2.9 billion in 2006. In June 1998, the Healthcare Financing Administration (HCFA; CMS), proposed an ASC rule in which at least 60% of interventional procedures were eliminated from ASCs and the remaining 40% faced substantial cuts in payments. Following the publication of this rule, based on public comments and demand, Congress intervened and delayed implementation of the rule for several years. The Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA) granted broad statutory authority to the Secretary of Health and Human Services to design a new ASC payment system based on the hospital outpatient payment system. The Centers for Medicare and Medicaid (CMS) published its proposed outpatient prospective system for ASCs in 2006, setting ASC payments at 62% of HOPD payments. This rule faced substantial opposition from providers, patients, and Congress. Consequently, CMS revised the rule with a 4-year transition formula to provide ASCs with 65% of HOPD payments. Based on the new proposed rule, most interventional pain management procedures in ASCs will lose approximately 3% to 5% without taking into account that there have not been any increments since 2004, except for a few small increases for some procedures, along with the addition of office procedures, which can now be performed in an ASC setting. However, payments for procedures moved from the office setting to ASCs remain at the lower office rates, which face substantial cuts on their own. The proposed CMS rule will have widespread effects on physician payments, ASC payments, and particularly interventional pain management physicians.