Outpatient Anterior Cervical Discectomy And Fusion Research Articles

Anterior Cervical Discectomy and Fusion in the Ambulatory Surgery Center Versus Inpatient Setting: One-Year Cost-Utility Analysis.

Retrospective analysis of prospectively collected data. Assess the cost-utility of anterior cervical discectomy and fusion (ACDF) performed in the ambulatory surgery center (ASC) versus inpatient hospital setting for Medicare and privately insured patients at one-year follow-up. Outpatient ACDF has gained popularity due to improved safety and reduced costs. Formal cost-utility studies for ambulatory versus inpatient ACDF are lacking, precluding an accurate assessment of cost-effectiveness. A total of 6504 patients enrolled in the Quality Outcomes Database (QOD) undergoing one-level to two-level ACDF at a single ASC (520) or the inpatient hospital setting (5984) were compared. Propensity matching generated 748 patients for analysis (374 per cohort). Demographic data, resource utilization, patient-reported outcome measures, and quality-adjusted life-years (QALYs) were assessed. Direct costs (1-year resource use×unit costs based on Medicare national allowable payment amounts) and indirect costs (missed workdays×average US daily wage) were recorded. Incremental cost-effectiveness ratios were calculated. Complication rates and improvements in patient-reported outcome measures and QALYs were similar between groups. Ambulatory ACDF was associated with significantly lower total costs at 1 year for Medicare ($5879.46) and privately insured ($12,873.97) patients, respectively. The incremental cost-effectiveness ratios for inpatient ACDF was $3,674,662 and $8,046,231 for Medicare and privately insured patients, respectively, reflecting unacceptably poor cost-utility. Inpatient ACDF is associated with significant increases in total costs compared to the ASC setting without a safety, outcome, or QALY benefit. The ASC setting is a dominant option from a health economy perspective for first-time one-l to two-level ACDF in select patients compared to the inpatient hospital setting.

138. Racial disparities in utilization of and short-term outcomes following cervical disc replacement vs anterior cervical discectomy and fusion

138. Racial disparities in utilization of and short-term outcomes following cervical disc replacement vs anterior cervical discectomy and fusion

25. Perioperative complications associated with epidural injections followed by cervical decompression and fusion

<h3>BACKGROUND CONTEXT</h3> Cervical epidural steroid injections (CESIs) are widely used to alleviate pain caused by degenerative diseases of the cervical spine. However, some data suggest a potential link between CESIs and infection rates following fusion surgeries. No prior studies have assessed the association between CESI and other postoperative outcomes such as hematomas, revision rates, or wound complications following anterior cervical discectomy and fusion (ACDF) and posterior cervical decompression and fusion (PCDF). Therefore, using a national dataset, we aimed to explore whether an association exists between preoperative CESIs and a variety of serious complications following ACDF and PCDF surgery. <h3>METHODS</h3> In this retrospective cohort study, we queried the IBM MarketScan national claims dataset (after IRB approval) and included adult patients who had undergone inpatient or outpatient ACDF or PCDF surgery due to disc herniation, stenosis, radiculopathy, spondylosis, or myelopathy from January 2014 to September 2017. Current procedural terminology codes were used to identify patients who received a CESI within one year prior to their surgery. Multivariable logistic regression measured the association between preoperative CESI and postoperative rates of 90-day infection, hematoma, wound complications, revision surgery, or combined complications (the former first three complications). We report odds ratios (OR) and 95% confidence intervals (CI). <h3>RESULTS</h3> Among 44,777 ACDF patients, 31.2% (n=13,950) received a preoperative CESI. For PCDF, 3,284 patients underwent the surgery of which 22.3% (n=734) received a preoperative CESI. The median time from most recent CESI to ACDF surgery is 76 days (interquartile range 41-144 days) and 95 days (interquartile range 49-176 days) for PCDF. Among ACDF patients, preoperative CESI was associated with lower odds of developing a hematoma following ACDF (OR 0.60; 95% CI 0.37-0.99; p=0.0453); no significant associations existed for the other outcomes including infection (OR 0.98; 95% CI 0.77-1.26; p=0.8846), revision surgery (OR 0.94; 95% CI 0.71-1.23; p=0.6300), wound complications (OR 0.92; 95% CI 0.71-1.17; p=0.4865) or combined complications (OR 0.88; 95% CI 0.73-1.07; p=0.1904). In the PCDF cohort, no significant associations existed between preoperative CESI and post-PCDF infection (OR 1.26; 95% CI 0.82-1.95; p=0.2962), revision surgery (OR 1.96; 95% CI 0.91-4.18; p=0.0842), wound complications (OR 1.11; 95% CI 0.71-1.72; p=0.6608) or combined complications (OR 1.14; 95% CI 0.78-1.68; p=0.4929). <h3>CONCLUSIONS</h3> Our study is the first to assess a broad complication profile that includes hematoma rates, infection rates, revision rates, and wound complications following ACDF and PCDF surgeries. We found no association between preoperative CESI and the aforementioned complications following ACDF and PCDF which supports first-hand clinical outcomes. Future work will aim to delineate the role of timing of CESI before ACDF and PCDF surgery, and the impact of quantity of CESIs on complication risks. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Increase in surgeons performing outpatient anterior cervical spine surgery leads to a shift in case volumes over time

BackgroundPrior studies have demonstrated an increase in the performance of outpatient anterior cervical surgery. The degree to which this increase is due to volume increase per individual surgeon versus increase in individual surgeons performing outpatient cervical surgery is unknown. MethodsPatients undergoing anterior cervical discectomy and fusion (ACDF) or cervical disk arthroplasty (CDA) between 2010 and 2018 in NY state were identified. As a comparison we also evaluated trends for inpatient ACDF and CDA. Annual outpatient case volumes were calculated and defined as being high (> 20/year), intermediate (>5 and ≤ 20/year) or low (>1 and ≤ 5/year). Descriptive statistics were used to report temporal trends and Poisson regression was used to test for statistical significance. We also analyzed trends in various operative metrics by surgeon volume. ResultsIn 2010, there were 96 surgeons who performed outpatient ACDF or CDA on a total of 1,855 patients. In 2018, this increased to 253 surgeons performing outpatient ACDF or CDA on a total of 3,372 patients. In comparison, there were 350 surgeons performing 6,783 inpatient cases in 2010 and 376 surgeons performing 6,796 inpatient cases in 2018. The average annual outpatient case volume decreased from 18.8 (95% CI, 13.5 – 24.1) to 12.2 (95% CI, 10.0 – 14.3) surgeries per surgeon. The percentage of surgeons with a high case volume also decreased from 30.2% in 2010 to 10.7% in 2018, whereas the percentage with a low case volume increased (32.3% to 49.8%). Differences between high and low volume surgeons in operative time, length of stay and total charges widened over time. ConclusionThe increase in outpatient anterior cervical surgery appears to be primarily driven by a greater number of surgeons performing ACDF and CDA on an outpatient basis, as opposed to increased case volumes for each surgeon. In contrast, trends for inpatient anterior cervical surgery were stable.

Presence and Severity of Mental Illness Is Associated With Increased Risk of Postoperative Emergency Visits, Readmission, and Reoperation Following Outpatient ACDF: A National Database Analysis.

Retrospective cohort study. The purpose was to compare rates of postoperative ED visits, readmission, and reoperation between patients with and without preexisting mental illness undergoing outpatient anterior cervical discectomy and fusion (ACDF). A retrospective review of the Mariner Database was conducted on patients who underwent ACDF between 2010 and 2017. Exclusion criteria included same day revision surgery and patients with a history of spine infection, trauma, or neoplasm. Patients were grouped into 3 categories: those with existing history of anxiety and/or depression, those with severe mental illness, and those without any history of mental illness. Severe mental illness was defined as a combination of diagnosis including schizophrenia, bipolar disorder, and/or psychotic disorder. Outcome measures were analyzed by comparing groups using multivariate logistic regression. Significance was set at P < 0.05. Patients with anxiety/depression and patients with severe mental illness both had significantly increased risk of ED visits and readmission at 30-day and 90-day intervals. Compared to patients without mental illness, patients with severe mental illness (OR 1.93, P < 0.001) had significantly increased rates of reoperation at 90-days and 1-years postoperatively. Patients with anxiety/depression did not have increased rates of reoperation relative to patients without anxiety/depression at any time interval (P > 0.05). Anxiety/depression as well as more severe psychiatric disease such as Schizophrenia and Bipolar disorder were significantly associated with increased healthcare utilization following outpatient ACDF. Patients with preexisting mental illness undergoing outpatient ACDF should be carefully evaluated preoperatively and closely followed postoperatively to reduce risk of adverse events.

Development of predictive algorithms for length of stay greater than one day after one- or two-level anterior cervical discectomy and fusion

Strategies for improving value-based healthcare in anterior cervical discectomy and fusion (ACDF) include a shift towards outpatient procedures. The primary outcomes was prolonged length of stay defined as length of stay greater than one day. Overall, 2917 patients underwent ACDF, of which 35.2% (n = 1027) had length of stay greater than one day. The variables used for prediction of prolonged LOS were age, sex, marital status, private insurance, myelopathy, patient-reported drug allergies, presence of at least one medical comorbidity, preoperative medications, and preoperative laboratory values. These models may be helpful for triaging the patients most likely to benefit from outpatient ACDF.

Cost Analysis of Outpatient Anterior Cervical Discectomy and Fusion at an Academic Medical Center without Dedicated Ambulatory Surgery Centers

Anterior cervical discectomy and fusion (ACDF) are increasingly performed at ambulatory surgical centers (ASCs). Academic centers lacking dedicated ASCs must perform these at large university hospitals, which pose unique challenges to cost savings and efficiency. To describe the safety and cost of outpatient ACDF at a major academic medical center without a dedicated ASC. ACDFs performed from 2015 to 2018 were retrospectively reviewed. Cases were performed at the major tertiary university hospital or a satellite university hospital dedicated to outpatient surgery. Patient demographics, surgical characteristics, perioperative complications, fusion at 12 months, and cost were collected. A total of 470 patients were included. The mean age was 56 years, with 255 women (54.3%). When comparing same-day discharge, overnight observation, or inpatient admission, there were no differences in age, gender, or number of levels fused. Same-day and overnight observation cases were associated with shorter procedure duration and less estimated blood loss. There were no differences in perioperative complications, 30-day readmissions, or fusion at 12 months. Direct and total costs were lowest for same-day cases, followed by overnight observation and inpatient admissions (P < 0.001). Academic centers without dedicated ASCs can safely perform ACDF as a same-day or overnight observation procedure with significant reductions in cost. The lack of a dedicated ASC should not preclude academic centers from allocating appropriately selected patients into same-day or overnight observation care pathways. This strategy can improve resource utilization and preserve precious hospital resources for the most critically ill patients while also allowing these centers to build viable outpatient spine practices.

Are outpatient three- and four-level anterior cervical discectomies and fusion safe?

BACKGROUND CONTEXTThe safety of outpatient one- and two-level anterior cervical discectomy and fusion (ACDF) has been validated in a number of recent studies. However, recent advancements in anesthetic and surgical technique have rendered procedures previously only performed in an inpatient setting, such as three- and four-level ACDF, potentially amenable to outpatient management. PURPOSEThe present study aimed to investigate the safety of outpatient three- and four-level ACDF. STUDY DESIGNRetrospective cohort study PATIENT SAMPLEThe National Surgical Quality Improvement Program – a large, prospectively-collected registry – was queried to identify patients undergoing three- and four-level ACDF in an inpatient and outpatient setting. OUTCOME MEASURESThe rates of total complications, perioperative blood transfusion, and unplanned hospital readmission in three- and four-level ACDF by inpatient or outpatient surgery status. METHODSBaseline patient characteristics and 30-day outcomes were tabulated and compared by inpatient or outpatient status using bivariate analysis. A multivariate analysis was also employed to adjust for differences in baseline patient characteristics when comparing outcomes, and was also used to identify independent predictors of complications and readmissions in patients undergoing three- and four-level ACDF. RESULTSIn total 3,441 patients underwent three- or four-level ACDF, with 2,718 (79.0%) procedures occurring inpatient and 723 (21.0%) outpatient. Of patients undergoing outpatient ACDF, 596 patients (82.4%) underwent a three-level and 127 patients (17.6%) underwent four-level procedures. There was an increase in the utilization of outpatient procedures, increasing from 7.0% to 32.9% between 2011 and 2018. Patients undergoing outpatient surgery were younger, white, more likely to have three-level fusions (vs four-level), had a lower American Society of Anesthesiologists (ASA) classification, and were less likely to have a history of diabetes mellitus or dependent functional status. Among the inpatient and outpatient cohorts, there was no significant difference in the rates of total complications (4.49% vs 2.49%) or unplanned readmissions (4.96% vs 3.72%). Increasing age, operative duration, and ASA classification were independent predictors of complications and readmissions, however, inpatient or outpatient surgery status and number of levels fused was not. CONCLUSIONSThis present study represents one of the largest cohorts of patients undergoing outpatient three- and four-level ACDF. Outpatient multilevel ACDF is performed in younger and healthier patients, with three-level procedures more commonly the four-level. There was no observed increased rates of total complications or readmissions in patients undergoing outpatient relative to inpatient surgery, however, we did identify increased age, operative duration, and ASA classification as independent predictors of these complications. Patient selection for outpatient procedures is of the highest importance, and future studies developing reproducible selection criteria are warranted.

Anterior Cervical Discectomy and Fusion in the Outpatient Ambulatory Surgery Setting: Analysis of 2000 Consecutive Cases.

In an effort to improve efficiency of care, ambulatory surgery centers (ASCs) have emerged as lower-cost options. Anterior cervical discectomy and fusion (ACDF) is one of the most prevalent spine surgeries performed and rarely requires overnight stays in the hospital, supporting its migration to the ASC. Recent analyses have called into question the safety of outpatient ACDF, potentially slowing its adoption. ASC-ACDF studies have largely been limited to small series, precluding an accurate assessment of safety. To analyze 2000 ASC-ACDF cases, describe patient selection and perioperative protocol, and report associated safety profile. A total of 2000 patients who underwent 1 to 3 level ACDF in a single ASC from 2006 to 2018 were included in this retrospective analysis. Patients were observed in a 4-h postanesthesia care unit (PACU) with a multimodal pain management regiment. Data were collected on patient demographics, comorbidities, operative details, and 30- and 90-d morbidity. Of the 2000 patients, 10 (0.5%) required transfer to an inpatient setting within the 4-h observation. Reasons for transfer included hematoma (2), pain control (2), cerebrospinal fluid leak (1), and medical complications (5). Six patients (0.3%) underwent reoperation within 30 d. All-cause 30-d readmission was 1.9%. An analysis of 2000 ACDF patients in an ASC setting with a standardized perioperative protocol demonstrates that surgical complications occur at a low rate (<1%) and can be appropriately diagnosed and managed in a 4-h PACU. In an effort to decrease healthcare costs, surgeons can safely perform ACDFs in an ASC utilizing patient selection criteria and perioperative management protocols similar to those reported here.

Safety of Outpatient Anterior Cervical Discectomy and Fusion: A Systematic Review and Meta-Analysis.

Anterior cervical discectomy and fusion (ACDF) is being increasingly offered on an outpatient basis. However, the safety profile of outpatient ACDF remains poorly defined. To review the medical literature on the safety of outpatient ACDF. We systematically reviewed the literature for articles published before April 1, 2018, describing outpatient ACDF and associated complications, including incidence of reoperation, stroke, thrombolytic events, dysphagia, hematoma, and mortality. A random-effects analysis was performed comparing complications between the inpatient and outpatient groups. We identified 21 articles that satisfied the selection criteria, of which 15 were comparative studies. Most of the existing studies were retrospective, with a lack of level I or II studies on this topic. We found no statistically significant difference between inpatient and outpatient ACDF in overall complications, incidence of stroke, thrombolytic events, dysphagia, and hematoma development. However, patients undergoing outpatient ACDF had lower reported reoperation rates (P<.001), mortality (P<.001), and hospitalization duration (P<.001). Our meta-analysis indicates that there is a lack of high level of evidence studies regarding the safety of outpatient ACDF. However, the existing literature suggests that outpatient ACDF can be safe, with low complication rates comparable to inpatient ACDF in well-selected patients. Patients with advanced age and comorbidities such as obesity and significant myelopathy are likely not suitable for outpatient ACDF. Spine surgeons must carefully evaluate each patient to decide whether outpatient ACDF is a safe option. Higher quality, large prospective randomized control trials are needed to accurately demonstrate the safety profile of outpatient ACDF.

Outpatient anterior cervical discectomy and fusion in the ambulatory surgery center setting: safety assessment for the Medicare population.

Several studies have demonstrated that anterior cervical discectomy and fusion (ACDF) surgery in the outpatient versus hospital setting provides improved efficiency, cost-effectiveness, and patient satisfaction without a compromise in safety or outcome. Recent anecdotal reports, however, have questioned whether outpatient ACDF surgery is safe in the > 65-year-old Medicare population. To date, no clinical study has assessed the safety of outpatient ACDF in an ambulatory surgery center (ASC), specifically in a Medicare population. The authors set out to analyze their 3-year experience with Medicare-enrolled patients undergoing ACDF surgery at a single ASC to determine its safety profile, perioperative care protocol, and associated outcomes. A retrospective analysis of 119 consecutive patients > 65 years (Medicare-eligible) who underwent 1-, 2-, or 3-level ACDF at a single ASC from 2015 to 2018 (since Medicare payment approval) was conducted. All patients were in American Society of Anesthesiologists classes I-III. Postoperatively, patients were observed for a minimum of 4 hours in a recovery setting for the following factors: neck swelling, neurological status, ability to swallow solid food, and urination capacity. All patients received a multimodal pain management regimen prior to discharge home. Data were collected on patient demographics, comorbidities, operative details, and all perioperative and 90-day morbidity. Complete data were available for all 119 consecutive Medicare-eligible patients, 97 (81.5%) of whom were actively enrolled in Medicare. One-, 2-, and 3-level ACDFs were performed in 103 (86.6%), 15 (12.6%), and 1 (0.8%) patients, respectively. No patients required return to the operating room for intervention within the 4-hour postanesthesia care unit observation window. No patients required transfer from the ASC to the hospital setting for further observation or intervention. Thirty-day adverse events were reported in 2.4% of cases, all of which resolved by 90 days after surgery. The incidence of 90-day hospital readmission was 1.7% (n = 2), with 1 patient (0.8%) requiring reoperation at the index level for deep infection. All-cause 90-day mortality was 0%. An analysis of consecutive Medicare patients (American Society of Anesthesiologists classes I-III) who underwent mostly 1-level and some 2-level ACDFs in an ASC setting demonstrates that surgical complications occur at a low rate with a safety profile similar to that reported for both inpatient ACDF and patients younger than 65 years. In an effort to reduce cost and improve efficiency of care, surgeons can safely perform ACDF in the Medicare population in an ASC environment utilizing patient selection criteria and perioperative management similar to those reported here.

Same-Day Anterior Cervical Discectomy and Fusion-Our Protocol and Experience: Same-Day Discharge After Anterior Cervical Discectomy and Fusion in Suitable Patients has Similarly Low Readmission Rates as Admitted Patients.

Outpatient anterior cervical discectomy and fusion (ACDF) is performed frequently, with studies demonstrating similar complication and readmission rates compared to traditional admission. Advantages include cost effectiveness, as well as lower risk of nosocomial infections and medical errors, which lead to quicker recovery and higher patient satisfaction. Protocols are needed to ensure that outpatient ACDF occurs safely. The objective of this study was to develop and implement a protocol with patient selection and discharge criteria for patients undergoing same-day discharge (SDD) ACDF and assess readmission rates. A retrospective chart review was performed to identify patients undergoing 1 or 2 level primary ACDF between March 2016 and March 2017 who were eligible for SDD according to the institutional protocol (Figure 1, Table 2). Patients with identical surgery and discharge dates were grouped as SDD, and admitted patients were grouped as same-day admission (SDA). Using our electronic health record's analytics, readmissions in the 90-day postoperative period were identified. Of the 434 patients identified, 126 patients were SDD, and 308 were SDA. Baseline characteristics such as age, operative time, and time in the recovery room were significantly different between the 2 groups (Table 2). The average length of stay of admitted patients was 1.48 days, with 77% discharged on postoperative day 1. There was an overall, noninferior readmission rate of 0.8% in the SDD group compared to 0.6% in the SDA group (P = .86). The results of this study support the feasibility of outpatient ACDF and add a patient selection and discharge criteria to the literature. Proper identification of suitable patients using our protocol results in a noninferior readmission rate, allowing surgeons to continue to safely perform these surgeries with a low readmission rate. 3. SDD is safe in the appropriate patient population.

A Comparison of 30-Day Hospital Readmission and Complication Rates After Outpatient Versus Inpatient 1 and 2 Level Anterior Cervical Discectomy and Fusion Surgery: An Analysis of a Medicare Patient Sample

Same-day surgery has been demonstrated to be a safe and cost-effective alternative to traditional inpatient surgery. Several studies have demonstrated no differences in the postoperative complication profile or 30-day hospital readmission rates with outpatient versus inpatient anterior cervical discectomy and fusion (ACDF). However, none of these studies compared the outcomes in elderly patients (aged >65 years) undergoing ACDF. Whether the results from previous studies can be applied to this subgroup pf patients remains unknown. The aim of the present study was to compare the 30-day hospital readmission rates for Medicare patients (aged >65 years) undergoing outpatient versus inpatient ACDF. We performed a retrospective analysis of a Medicare database, including data from 17,421 patients. Of the 17,421 patients, 16,386 had undergone inpatient ACDF and 1035, outpatient ACDF. Age, sex, comorbidities, postoperative complications, readmission rates, and overall financial costs were compared between the 2 cohorts. In a Medicare sample (aged >65 years), inpatient ACDF was associated with a greater incidence of postoperative complications compared with outpatient ACDF. Outpatient surgery was associated with significantly lower rates of postoperative complications (urinary tract infection, surgical site infection, deep vein thrombosis, pulmonary embolism, and myocardial infarction) and significantly lower treatment costs (P ≤ 0.001). All-cause 30-day hospital readmission rates were also greater for inpatients (10.1% vs. 4%; P= 0.17). The results from the present study suggest that outpatient ACDF appears to be safe and effective with low complication and readmission rates in a Medicare patient sample.

Safety of Outpatient Single-level Cervical Total Disc Replacement: A Propensity-Matched Multi-institutional Study.

A retrospective cohort comparison study. The aim of this study was to investigate the perioperative adverse event profile of cervical total disc replacement (CTDR) performed as an outpatient relative to inpatient procedure. Recent reimbursement changes and a push for safe reductions in hospital stay have resulted in increased interest in performing CTDRs in the outpatient setting. However, there has been a paucity of studies investigating the safety of outpatient CTDR procedures, despite increasing frequency. Patients who underwent single-level CTDR were identified in the 2005 to 2016 National Surgical Quality Improvement Program database. Outpatient versus inpatient procedure status was defined by length of stay, with outpatient being less than 1 day. Patient baseline characteristics and comorbidities were compared between the two groups. Propensity score matched comparisons were then performed for 30-day perioperative complications and readmissions between the two cohorts. In addition, perioperative outcomes of outpatient single-level CTDR versus matched outpatient single-level anterior cervical discectomy and fusion (ACDF) cases were compared. In total, 373 outpatient and 1612 inpatient single-level CTDR procedures were identified. After propensity score matching was performed to control for potential confounders, statistical analysis revealed no significant difference in perioperative complications between outpatient versus matched inpatient CTDR. Notably, the rate of readmissions was not different between the two groups. In addition, there was no difference in rates of perioperative adverse events between outpatient single-level CTDR versus matched outpatient single-level ACDF. The perioperative outcomes evaluated in the current study support the conclusion that, for appropriately selected patients, single-level CTDR can be safely performed in the outpatient setting without increased rates of 30-day perioperative complications or readmissions compared with inpatient CTDR or outpatient single-level ACDF. 3.

Outpatient and Inpatient Readmission Rates of 1- and 2-Level Anterior Cervical Discectomy and Fusion Surgeries

This study looks at the various comorbidities and postoperative complications and their impact on readmission rates of patients undergoing outpatient versus inpatient 1- and 2-level anterior cervical discectomy and fusion (ACDF). With increasing costs within the United States medical system, one emerging cost-saving strategy is to evolve traditional inpatient procedures into outpatient same-day surgeries. However, patient safety remains a crucial priority. A total of 28,427 patients were analyzed, with 26,368 undergoing inpatient ACDF surgery and 2059 undergoing outpatient ACDF surgery. Age, sex, comorbidities, postoperative complications, readmission rates, and overall financial cost were compared between both cohorts. Data from 28,427 one- and two-level ACDF procedures that were split between inpatient and outpatient were collected. Thirty-day readmission rates were significantly lower in outpatients than inpatients (4% vs. 10.1%, P < 0.001). Inpatients had higher rates of urinary tract infection (2.4% vs. 1.4%), deep vein thrombosis (0.6% vs. 0%), and myocardial infarction (0.2% vs. 0%), whereas outpatients had higher rates of pulmonary embolism (7.7% vs. 0.4%). Outpatients had increased readmission risk with comorbidities of diabetes (odds ratio [OR], 48.93; P < 0.001), smoking (OR, 4.6; P < 0.001), body mass index ≥30 (OR, 2392; P < 0.001). The average cost of outpatient surgery was less than that of inpatient surgery ($7774.8 vs. $7956.75, P=0.0444). This study suggests that in the appropriately selected patients, ACDF can safely be performed in an outpatient setting.

Thursday, September 27, 2018 8:30 AM–9:30 AM Best Papers: 104. Ambulatory anterior cervical discectomy and fusion is associated with a higher risk of perioperative complications

BACKGROUND CONTEXT With the changing landscape of health care, outpatient spine surgery is more commonly performed to reduce cost and improve efficiency. Anterior cervical discectomy and fusion (ACDF) is one of the mo st common spine surgeries performed and demand is expected to increase with an aging population. PURPOSE The purpose of this study was to determine the nationwide trends and complication rates associated with outpatient ACDF as compared to inpatient ACDF. STUDY DESIGN/SETTING This study is a retrospective review utilizing the Humana subset of the PearlDiver insurance records database. PATIENT SAMPLE The patient sample consisted of patients undergoing single level ACDF (CPT-22551 AND ICD-9-816.2) as either outpatients or inpatients from 2011 to 2016. OUTCOME MEASURES Perioperative medical and surgical complications were identified by querying for relevant International Classification of Diseases and Current Procedural Terminology codes. METHODS The incidence of perioperative medical and surgical complications was determined after the database query was performed. Multivariate logistic regression adjusting for age, gender and Charlson Comorbidity Index was used to calculate odds ratios (OR) of complications among outpatients relative to inpatients undergoing ACDF. RESULTS Cohorts of 1,215 patients who underwent outpatient ACDF and 10,964 patients who underwent inpatient ACDF were identified. The median age was in the age 65-69 age group for both cohorts. The annual relative incidence of outpatient ACDF increased from 0.11 in 2011 to 0.22 in 2016 (R2=0.82, p=.04). Adjusting for age, gender and comorbidities, patients undergoing outpatient ACDF were more likely to undergo revision surgery for posterior fusion at both 6 months (OR 1.58, CI 1.27–1.96, p CONCLUSIONS Outpatient spine surgery is growing increasingly popular due to changes in health care delivery and greater attention to cost reduction and improved efficiency. Data collected from a national private insurance database demonstrates greater risk of perioperative surgical complications associated with outpatient ACDF, including revision anterior and posterior fusion, as well as higher risk for postoperative acute renal failure. Candidates for outpatient ACDF should be counseled and carefully selected to reduce these risks. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Ambulatory anterior cervical discectomy and fusion is associated with a higher risk of revision surgery and perioperative complications: an analysis of a large nationwide database

Background ContextWith the changing landscape of health care, outpatient spine surgery is being more commonly performed to reduce cost and to improve efficiency. Anterior cervical discectomy and fusion (ACDF) is one of the most common spine surgeries performed and demand is expected to increase with an aging population. PurposeThe objective of this study was to determine the nationwide trends and relative complication rates associated with outpatient ACDF. Study Design/SettingThis is a large-scale retrospective case control study. Patient SampleThe patient sample included Humana-insured patients who underwent one- to two-level ACDF as either outpatients or inpatients from 2011 to 2016 Outcome MeasuresThe outcome measures included incidence and the adjusted odds ratio (OR) of postoperative medical and surgical complications within 1 year of the index surgery. Materials and MethodsA retrospective review was performed of the PearlDiver Humana insurance records database to identify patients undergoing one- to two-level ACDF (Current Procedural Terminology [CPT]-22551 and International Classification of Diseases [ICD]-9-816.2) as either outpatients or inpatients from 2011 to 2016. The incidence of perioperative medical and surgical complications was determined by querying for relevant ICD and CPT codes. Multivariate logistic regression adjusting for age, gender, and Charlson Comorbidity Index was used to calculate ORs of complications among outpatients relative to inpatients undergoing ACDF. ResultsCohorts of 1,215 patients who underwent outpatient ACDF and 10,964 patients who underwent inpatient ACDF were identified. The median age was in the 65–69 age group for both cohorts. The annual relative incidence of outpatient ACDF increased from 0.11 in 2011 to 0.22 in 2016 (R2=0.82, p=.04). Adjusting for age, gender, and comorbidities, patients undergoing outpatient ACDF were more likely to undergo revision surgery for posterior fusion at both 6 months (OR 1.58, confidence interval [CI] 1.27–1.96, p<.001) and 1 year (OR 1.79, CI 1.51–2.13, p<.001) postoperatively. Outpatient ACDF was also associated with a higher likelihood of revision anterior fusion at 1 year postoperatively (OR 1.46, CI 1.26–1.70, p<.001). Among medical complications, postoperative acute renal failure was more frequently associated with outpatient ACDF than inpatient ACDF (OR 1.25, CI 1.06–1.49, p=.010). Adjusted rates of all other queried surgical and medical complications were comparable. ConclusionsOutpatient ACDF is increasing in frequency nationwide over the past several years. Nationwide data demonstrate a greater risk of perioperative surgical complications, including revision anterior and posterior fusion, as well as a higher risk of postoperative acute renal failure. Candidates for outpatient ACDF should be counseled and carefully selected to reduce these risks.

Outpatient Anterior Cervical Discectomy and Fusion is Associated With Fewer Short-term Complications in One- and Two-level Cases: A Propensity-adjusted Analysis.

Retrospective cohort study of prospectively collected data from the National Surgical Quality Improvement Program (NSQIP) database. To determine the postoperative morbidity of one- and two-level outpatient anterior cervical discectomy and fusion (ACDF) relative to inpatient cases, and risk factors for postdischarge complications. ACDF is increasingly performed as an outpatient procedure, with evidence demonstrating outpatient one-level ACDF to be associated with fewer postoperative complications than inpatients. The postoperative morbidity and safety of outpatient two-level ACDF as a separate cohort is not well understood. ACDF cases from NSQIP 2011 to 2014 were identified. Differences in baseline characteristics between inpatient and outpatient cases were determined, and propensity score adjustment was used to account for selection bias. One- and two-level ACDF cohorts were analyzed separately. Unadjusted and propensity-adjusted multivariable logistic regressions were performed to determine the risk of postoperative complications in outpatient cases relative to inpatient cases, and predictors of postdischarge complications. A total of 22,006 ACDF cases were included, of which 4759 were outpatient procedures. Propensity-adjusted differences in preoperative characteristics were all P > 0.5, indicating successful adjustment of selection bias. Among 6890 two-level cases, of which 1429 (20.7%) were outpatient, the overall unadjusted rate of complications was 1.47% for outpatients and 3.94% for inpatients, P < 0.001. Propensity-adjusted multivariable regression showed a lower rate of postoperative complications in the outpatient cohort (odds ratio 0.48, 95% confidence interval 0.30-0.75). Greater comorbidity burden as measured by Charlson Comorbidity Index, higher American Society of Anesthesiologists class, chronic steroid use, hypertension, and male sex were independent risk factors for postdischarge complications. After adjusting for selection bias and patient risk factors, outpatient two-level ACDF was not associated with increased postoperative morbidity relative to inpatients, and may be considered in appropriately indicated patients. 3.

Inpatient versus Outpatient Anterior Cervical Discectomy and Fusion: A Perioperative Complication Analysis of 259,414 Patients From the Healthcare Cost and Utilization Project Databases.

Anterior cervical discectomy and fusion (ACDF) is one of the most common operations utilized to address pathology of the cervical spine. Few reports have attempted to compare complications associated with inpatient versus outpatient ACDF. The Nationwide Inpatient Sample (NIS) from 2001-2012 and the State Ambulatory Services Database (SASD) for New Jersey (NJ) from 2003-2012 were used for analysis. Patients receiving ACDF (defined as anterior cervical fusion (ICD-0 code=81.02) + excision of intervertebral disc (80.51)) were segmented into an inpatient group derived from the NIS, and an outpatient group derived from the NJ SASD. Patients receiving > 2 levels fused (ICD-9 codes 81.63-81.64), or surgery for cancer (ICD-9 codes 140-239), or trauma (ICD-9 codes=805.0-806.9) were excluded. Propensity score matching (PSM) was used to adjust the analysis for patient age, race, sex, primary payer for care, and number of medical diagnoses. Of the 94,492,438 inpatients comprising the NIS from 2001-2012, 257,398 received ACDF. Of the 4,194,207 outpatients comprising the NJ SASD, 2,016 received ACDF. PSM of 10,080 patients (all 2,016 SASD and 8,064 from NIS) was performed, and subsequent analysis revealed that durotomy (P=0.001;OR=0.81), paraplegia, postoperative infection, hematoma/seroma (OR=0.14), respiratory complications, acute posthemorrhagic anemia and red blood cell transfusion (all P<0.001) were less frequent in outpatient versus inpatient ACDF (p<0.05). These results were similar to an unmatched analysis involving all of the NIS patients. Accepting the limitations of the NIS and SASD (inability to distinguish between one and two-level fusions, no long-term follow-up, potential selection bias, disparities between inpatient and outpatient ACDF populations), these findings indicate that for 1-2 level ACDF, perioperative complications, including durotomy, paraplegia, hematoma, and acute posthemorrhagic anemia were more commonly reported following inpatient ACDF. Future studies involving outpatient analysis of several states will be necessary to determine whether these results of outpatient ACDF are applicable nationwide.

Outpatient Anterior Cervical Discectomy and Fusion: An Analysis of Readmissions from the New Jersey State Ambulatory Services Database.

Anterior cervical discectomy and fusion (ACDF) performed as an outpatient has become increasingly common for treating cervical spine pathology. Few reports have attempted to assess readmissions following outpatient ACDF. This study was performed to address this issue using population-based databases. The State Ambulatory Services Database (SASD) for New Jersey (NJ) from 2003-2012 was used for analysis. Patients receiving ACDF (defined as anterior cervical fusion (ICD-0 code=81.02) + excision of intervertebral disc (80.51)) were extracted; those with three or more levels fused (ICD-9 codes 81.63-81.64), cancer (ICD-9 codes 140-239), or trauma (ICD-9 codes=805.0-806.9) were excluded. A series of perioperative complications including durotomy, red blood cell transfusion, acute posthemorrhagic anemia, paraplegia (weakness), and mortality were examined. Propensity score matching (PSM) was used to adjust the analysis for patient age, race, sex, primary payer for care, and number of diagnoses. The NJ SASD defined readmission as admission to the same facility within seven days of initial discharge. Two thousand sixteen (2,016) patients were found, 1,528 of whom had readmission data. Of these 1,528 patients, 83 (5.4%) required readmission. PSM was performed prior to comparing readmission versus non-readmission. While there was no difference in perioperative complications between the two groups, the small sample size of the readmission cohort prevented this analysis from having sufficient power. No patient requiring readmission had an initial length of stay greater than one day. Based on a 10-year outpatient analysis, fewer than 6% of outpatient 1-2 level ACDFs require readmission. Future studies involving outpatients from several states will be necessary to determine whether these results of outpatient ACDF are applicable nationwide.