Outpatient Surgery Center Research Articles

Transition from Private to Academic Anesthesia Provision Changes Process and Patient Centered Outcomes in an Ambulatory Surgery Center.

A recurring concern in the discussion of performance of anesthesia practices is that academic practitioners are slower, less efficient, or produce poorer operational outcomes than their private practice counterparts. A simple overnight 'swap' of a private anesthesia practice with an academic anesthesia practice took place in an outpatient surgery center where the case volume, case mix, surgeons, and staff remained the same. Operational and quality measures were analyzed for comparison between the practices over the span of two years. All patients who had a procedure at the outpatient surgery center in the year prior to the takeover and the year after were studied. Post-anesthesia care unit times, hospital transfer data, pain scores at discharge, opioids dispensed, and anesthesia control times were compared over two years. Charts were manually abstracted by non-clinical administrative staff who were unaware of the study hypothesis. Procedure data and clinical outcomes were compared between the two years using standard statistical techniques. After exchange to the academic group, the median (mean) pain score at post-anesthesia care unit (PACU) discharge was reduced from 2 (2.0) to 0 (1.7) (Wilcoxon rank sum test p< 0.001), and the odds of having moderate or severe pain was reduced by 32% (95% CI, 25, 39, p < 0.001) after adjusting for surgery type. The year-on-year average recovery room time was reduced by 13.9min (95% CI, 12.5, 15.4, p < 0.001) after adjusting for surgery type. There was a significant reduction in hospital transfer rate after changing groups (0.45% vs. 0.07%, Pearson chi square test p= 0.005). Hospital transfer rates, dispensed opioids in PACU, pain scores at discharge, and PACU times were all improved after the conversion from a private practice to an academic one, without a compromise in efficiency or throughput.

Hysteroscopic Approaches to the Removal of Malpositioned Intrauterine Devices (IUDs)

Study Objective The objectives of this video are to (1) demonstrate both common and uncommon clinical presentations of a malpositioned intrauterine device (IUD) and (2) demonstrate appropriate removal techniques, including those ideal for both the office and operating room setting. Design Surgical technique demonstration Setting All procedures were conducted at an academic medical center. Procedures were performed in the office setting and operating room where appropriate. The office setting includes both routine exam rooms and procedure suites. Operating room based procedures are performed in an outpatient surgery center. The patients are positioned in lithotomy using built-in table stirrups in the office and either candy cane or boot stirrups in the operating room. Patients or Participants Photo and video footage was collected from patients managed within the gynecology division at our institution. All patients agreed to the use of photos and videos for educational purposes via an informed consent process. Interventions Using a combination of surgical footage, 3-dimensional animation and imaging (ultrasound, MRI), the video progresses through several different scenarios of malpositioned and embedded IUDs and corresponding techniques for removal. These techniques include caudal traction, sharp dissection, electrosurgical dissection, cranial-caudal motion, and rotation. Measurements and Main Results n/a Conclusion This video reviews the clinical approach to the removal of malposition. The objectives of this video are to (1) demonstrate both common and uncommon clinical presentations of a malpositioned intrauterine device (IUD) and (2) demonstrate appropriate removal techniques, including those ideal for both the office and operating room setting. Surgical technique demonstration All procedures were conducted at an academic medical center. Procedures were performed in the office setting and operating room where appropriate. The office setting includes both routine exam rooms and procedure suites. Operating room based procedures are performed in an outpatient surgery center. The patients are positioned in lithotomy using built-in table stirrups in the office and either candy cane or boot stirrups in the operating room. Photo and video footage was collected from patients managed within the gynecology division at our institution. All patients agreed to the use of photos and videos for educational purposes via an informed consent process. Using a combination of surgical footage, 3-dimensional animation and imaging (ultrasound, MRI), the video progresses through several different scenarios of malpositioned and embedded IUDs and corresponding techniques for removal. These techniques include caudal traction, sharp dissection, electrosurgical dissection, cranial-caudal motion, and rotation. n/a This video reviews the clinical approach to the removal of malposition.

A Comparison of Surgical Costs between Interval Laparoscopic Sterilization Techniques

Study Objective The purpose of this study was to evaluate factors associated with cost variability between laparoscopic bilateral salpingectomy and tubal fulguration including operating room (OR) time, supply cost, total cost, and recovery time. Design Retrospective chart review. Setting Hospital-based operating room and outpatient surgery center at a community teaching hospital. Patients or Participants Total sample size was 1649 patients. Inclusion criteria were all patients who underwent laparoscopic bilateral salpingectomy or tubal fulguration between January 1, 2013 and December 31, 2019. Patients were excluded if any other procedure was performed at time of sterilization or if they were missing outcome data. Interventions None. Measurements and Main Results Patient demographic data collected included patient age, body mass index, self-reported race, and ethnicity. Outcome data collected included OR time, OR cost, supply cost, total cost, recovery time, and post-operative pain. Cost data was adjusted for medical inflation. Total cost data did not include anesthesia or surgeon cost. When comparing laparoscopic bilateral salpingectomy (n=342) to bilateral tubal fulguration (n=1307), salpingectomy cases had increased OR time, 71.9 minutes versus 55.5 minutes (p Conclusion Total procedure cost, including OR time and chargeable supply cost, was 45% more expensive for laparoscopic bilateral salpingectomy compared to tubal fulguration.

Patient health status and case complexity of outpatient surgeries at various facility types in the United States: An analysis using the National Anesthesia Clinical Outcomes Registry

Study objectiveAmong the various types of outpatient surgery centers, there are differences in higher American Society of Anesthesiologists Physical Status (ASA PS) scores and surgical complexity among patients who are undergoing surgery. The primary objective of this study was to describe the differences performed at various types of outpatient surgery facilities. DesignWe performed a retrospective analysis of the National Anesthesia Clinical Outcomes Registry (NACOR) data. SettingNACOR from 2012 to 2017. PatientsFrom 2012 to 2017, there were a total of 13,053,115 outpatient surgeries in the database. After removing cases with unknown facility type, the final study sample was 9,217,336. InterventionsNone. MeasurementsTo calculate the probability of either American Society of Anesthesiologists Physical Status (ASA PS) score ≥ 3 or physiologically complex cases (defined as Common Procedural Terminology start-up units ≥8), we performed mixed effects logistic regression for each institution per facility type, controlling for year and using facility identification as the random effect. We present the mean rate of these two classifications as case per 10,000 cases and report the 99.9% confidence interval (CI), to control for multiple comparisons. Main resultsAmong all cases, 5,919,844 (64.2%) were classified as ASA PS 1 or 2 and 254,110 (2.8%) of surgical procedures were considered physiologically complex. The mean rate of cases with ASA PS ≥ 3in the university setting was 2982 per 10,000 cases [99.9% CI 2701–3278 per 10,000 cases]. Large community hospitals had a higher proportion of ASA PS ≥3 patients, medium-sized hospitals had no difference, and all other facility types had a decreased proportion. The mean rate of cases that were physiologically complex in the university setting was 133 per 10,000 cases [99.9% CI 117–151 per 10,000 cases]. Large community hospitals had a higher proportion of physiologically complex cases, medium-sized and small-sized hospitals had no difference, and all other facility types had a decreased proportion. ConclusionsFreestanding and attached surgery centers exhibited smaller rates of patients that were ASA PS ≥ 3, as well as a decrease in surgically complex cases, when compared to university settings. This suggests that the level of conservativeness for patient and surgery appropriateness for outpatient surgery differs across various facility types.

Regional Nerve Block Complication Analysis Following Peripheral Nerve Block During Foot and Ankle Surgical Procedures

Category:Other; Ankle; Ankle Arthritis; BunionIntroduction/Purpose:Foot and ankle surgeries are often be accompanied by a peripheral nerve block as a method of reducing post-operative pain. The major nerve targeted is the popliteal nerve. The nerve can be supplemented with a target of the adductor canal or saphenous nerve. Higher than expected complication rates with peripheral nerve blocks has led to increased concern among both surgeons as well as patients. To our knowledge, no study has been able to identify risk factors that may predispose a patient to one of these complications. Our goal was to attempt to identify those risk factors.Methods:We reviewed patient charts who underwent a foot and ankle procedure between 2014 and 2018 as performed by the senior author. The review yielded 992 procedures performed across four surgical locations. Of these, 137 procedures were removed because no regional block was used. The remaining cases were analyzed for nerve complications, defined as sensory (paresthesia, numbness, tingling, or burning pain) or motor (weakness or paralysis) deficits along the distribution of a peripheral nerve. The patients were divided into blocked patients with and without complications. The groups were evaluated for demographic differences. The categories consisted of age, sex, diabetic status, smoking, previous procedures, previously diagnosed neuropathies, surgical location, body mass index (BMI), race, and insurance provider. Statistical analysis was performed using SAS software. To determine significance of these different factors, Chi-square values were obtained for each data set. Additionally, a regression analysis was performed to identify odds ratio for individual factors.Results:The overall complication rate was 10.1% with a total of 855 blocks given. The significant factors associated with a complication were age (p=0.0061), BMI (p=0.0031), location (p=0.0016), and smoking status (p=0.0026). Factors that were not significantly associated with complications were sex, diabetes status, previous procedures requiring a block, previously diagnosed neuropathies, race, and insurance provider. A regression analysis was performed to determine odds ratio for individual factors. Those with significant higher odds ratio were age between 40-65 years, normal or underweight BMI, surgery occurring at an Outpatient Surgery Center, and current smoker.Conclusion:Current literature has reviewed operative variables such as tourniquet time and epinephrine use, while others have looked at diabetes and age as predictors of nerve block complications. Our study focuses more on epidemiological factors that can predict an increased risk. Our study helped to reinforce the findings previous literature has found in regards to age and diabetes status. This study has also introduced some new factors that can help the surgeon decide if a nerve block is necessary for each surgical patient.

Headless vs. Headed Screws Fixation for Calcaneal Osteotomy and Subtalar Arthrodesis: What’s the Cost?

Category:Hindfoot; Ankle ArthritisIntroduction/Purpose:Screw prominence in the heel following calcaneal fixation has resulted in unacceptably high rates of symptomatic hardware and subsequent screw removal. The hardware removal rate following calcaneal screw fixation ranges from 11-50%. We are unaware of any cost analysis comparing headed screw fixation vs. headless screw fixation in the foot and ankle literature. Furthermore, there is no literature comparing the rate of subtalar arthrodesis following headed screw fixation vs. headless screw fixation.Methods:CPT codes were used to identify all patients that had a subtalar arthrodesis or displacement calcaneal osteotomy (with screw fixation) performed by a single orthopedic foot and ankle surgeon between 2010 and 2016. The cohort was divided into two groups by the type of screw fixation, 7.0 mm headless screw or 6.7 mm headed screw. Exclusion criteria included <2 years from the index surgery and AVN of the calcaneus or talus. Retrospective chart review was performed to collect demographic data, complications, and cause for screw removal. The primary outcome measure was the rate of symptomatic screw removal.Secondary outcome measure included subtalar arthrodesis as determined by CT or radiographic review. The expense associated with symptomatic hardware removal was determined and cost analysis was performed for the two groups.Results:Seventy-six patients underwent headless screw fixation for calcaneal osteotomy or subtalar arthrodesis, and only two patients (2.6%) required symptomatic screw removal. Fifty-four patients underwent headed calcaneal screw fixation, and twelve patients (22.2%) required symptomatic screw removal. Symptomatic hardware removal was performed more frequently in the headed screw group (p< 0.001). There was no difference in the rate of nonunion after subtalar arthrodesis between the two groups (p = 0.363). The calcaneal osteotomy healed in 100% of patients in both groups. The cost associated with isolated screw removal was compared for private insurance and Medicare at an outpatient surgery center. There was a $51,755 cost savings per 100 cases using headless screw fixation compared to headed screw fixation.Conclusion:The rate of symptomatic screw removal following calcaneal osteotomy or subtalar arthrodesis is lower with headless screw fixation compared to headed screw fixation. There was no difference in the rate of subtalar union between the two groups as a secondary outcome, but the study was underpowered. Although the headless screw implant is more expensive, cost analysis demonstrates a significant benefit when the expense of hardware removal is considered.

Immediate Postoperative Outcomes after Elective Outpatient Robotic Assisted Surgery: Early Results from a Community Outpatient Surgery Center

Swaminathan, Santosh MBBS; Panjwani, Suraj J. MBBS; Alexander Palesty, J. MD, FACS Author Information

A Pilot Study of Full-Endoscopic Annulus Fibrosus Suture Following Lumbar Discectomy: Technique Notes and One-Year Follow-Up

Background: An annulus fissure or defect will inevitably be left on the posterior annulus fibrosus after almost all kinds of lumbar discectomy, which may lead to unsatisfying postoperative pain relief and recurrence of the disc herniation. Objective: The objective of this research is to introduce the technique of full-endoscopic annulus fibrosus suture following lumbar discectomy through the transforaminal or interlaminar approach, and to analyze the clinical outcome of full-endoscopic lumbar discectomy and annulus fibrosus suture. Study Design: This study used a prospective cohort design. Setting: The research was conducted in a hospital and outpatient surgery center. Methods: A total of 50 patients with noncontained lumbar disc herniation treated with full-endoscopic lumbar discectomy and annulus fibrosus suture were treated in our department between January 2018 and November 2018. Full-endoscopic single-stitch suture via the transforaminal approach (Group T) or double-stitch suture via the interlaminar approach (Group I) was selected according to the level of lesion. Lumbar magnetic resonance imaging (MRI) was reexamined on the second day and 3 months after operation to evaluate the completeness of the discectomy and the adequacy of nerve decompression. Patients were followed up on the second day, 3 months, 6 months, and one year after operation to evaluate the relief of low back pain and leg pain, using a visual analog scale (VAS, 100-point scale). At 3 months, 6 months, and one year after operation, the patients were followed up for recovery of lumbar spine function, using the Oswestry Disability Index (ODI). At the one-year follow-up, the MacNab score was used to evaluate the clinical outcome, and the recovery of nerve root function (sensation, muscle strength, and reflex) was recorded. Results: All operations were successfully completed, including 27 cases in Group T and 23 cases in Group I. There were no surgical complications and no recurrence of lumbar disc herniation. Lumbar MRI reexaminations of all patients showed that the herniated disc was completely removed and the nerves were fully decompressed. Postoperative low back pain and leg pain were significantly relieved, and the ODI score was significantly improved (P &lt; .01) in both groups. At the one-year follow-up, the excellent and good rates as measured by the MacNab score were 92.6% in Group T and 91.3% in Group I with no significant difference between the 2 groups (P &gt; .05). The impaired sensation and muscle strength in the low extremities of evolved nerve root of the 2 groups of patients recovered significantly at the oneyear follow-up (P &lt; .01), but the tendon reflex did not recover significantly (P &gt; .05). Limitations: This is an observational cohort study with relatively small sample sizes and short-term follow-up. Conclusions: Full-endoscopic lumbar discectomy and annulus fibrosus suture through either the transforaminal or interlaminar approach are safe and effective minimally invasive spinal surgery techniques that can reduce the recurrence rate of lumbar disc herniation after full-endoscopic lumbar discectomy. Keywords: Annulus fibrosus suture; full-endoscope; lumbar disc herniation; lumbar discectomy; minimally invasive spinal surgery

Calabash Community Hospital

This case considers a $10 million investment in an outpatient surgery center by a not-for-profit community hospital in rural South Carolina. A member of the purchasing department, R. D. Scott, is invited to complete a discounted cash flow (DCF) analysis of the investment opportunity to help quantify the financial costs and benefits of the project in this not-for profit context. The analysis maintains substantial uncertainty regarding a number of key parameters. Excerpt UVA-F-1946 Apr. 15, 2020 Calabash Community Hospital As R. D. Scott left work on a Friday in early December 2019, it seemed like a perfect evening in Calabash, South Carolina. The temperature was 70 degrees, the smell of Lizard's Thicket fried chicken was wafting in the air, and Scott was on his way to cheer on his alma mater's Clemson Tigers as they took on the Virginia Cavaliers for a football conference championship. But then as he viewed the grassy field just beyond the parking lot—the site for a potential new facility—Scott was reminded of the drama of that morning's meeting. The Meeting Scott worked in the purchasing department for Calabash Community Hospital (CCH). He had been there long enough to know the hospitals' suppliers backward and forward. Business at the hospital had long been stable and profitable—a true cash cow. While work life was stable and comfortable at CCH, a growing group at the hospital was concerned about the relaxed nature of CCH management. They saw substantive changes in care at other hospitals in the region, including significant investments pouring into new facilities. The group anticipated a bleak future for CCH if the administrative team wasn't more aggressive. Emily Tang, chief financial officer for the hospital, was not among those advocating for change, but nonetheless, she had responded by organizing a team of administrators, doctors, and nurses to lead an effort to gather data on the feasibility of starting up an ambulatory (outpatient) surgical center (ASC) at CCH. Scott was a member of the team. . . .

Improvement in Postoperative Pain Control and Length of Stay With Peripheral Nerve Block Prior to Distal Radius Repair.

Distal radius repair is a common orthopedic surgery often performed at outpatient surgical centers. To date, little is known regarding optimal pain control in this setting. In this study, the authors evaluated patients who underwent distal radius open reduction and internal fixation (ORIF) in an outpatient surgery center setting. Comparisons between 2 surgical groups, peripheral nerve block without general anesthesia vs general anesthesia only, were recorded in terms of postoperative length of stay (LOS) in phase I, total LOS, and patient-reported pain level at discharge. The authors identified 80 patients undergoing distal radius ORIF from March to August 2016. A total of 37 (46.3%) patients received general anesthesia only and 43 (53.8%) patients received peripheral nerve block without general anesthesia. Overall, patients in the nerve block only group showed a statistically significant decrease in pain at discharge, as well as decreased phase I and total LOS. Although the power of the data is low relative to the number of distal radius procedures performed every year, there is a trend of better pain control and decreased LOS when using nerve blocks instead of general anesthesia. [Orthopedics. 2020;43(6):e549-e552.].

Regional Nerve Block Complication Analysis Following Peripheral Nerve Block During Foot and Ankle Surgical Procedures.

BackgroundFoot and ankle surgeries are frequently accompanied by a peripheral nerve block in order to reduce postoperative pain. Higher than expected complication rates with peripheral nerve blocks have led to increased concern among surgeons and patients. To our knowledge, no study conducted by the treating surgeon has identified risk factors that may predispose a patient to complications. Our goal was to attempt to identify those risk factors.MethodsWe reviewed patient charts of those who underwent an orthopedic foot and ankle procedure between 2013 and 2018, as performed by the senior author. This yielded 992 procedures performed across four surgical locations. Of these procedures, 137 procedures were removed because no block was used. The remaining cases were analyzed for nerve complications, defined as sensory or motor deficits along the distribution of a nerve. The patients were divided into those with and without complications and were evaluated for differences. Statistical analysis was performed using the SAS® software (SAS Institute Inc., Cary, North Carolina, USA).ResultsThe overall short-term complication rate was 10.1% and the long-term complication rate was 4.3%, with a total of 855 blocks given. Electromyographies (EMGs) were performed on 24.4% of the patients with a complication. Of the EMGs, 95.2% confirmed nerve complications in the distribution of the blocked nerve. The significant factors associated with complications were age, BMI, location, and smoking status. A regression analysis was performed to determine the odds ratio for individual factors. Those with significantly higher odds ratio were between 40 and 65 years of age, had normal or underweight BMI, underwent surgery at an outpatient surgery center, and were current smokers.ConclusionsOur study suggests that there are significant epidemiological factors in predicting postoperative complications related to a peripheral nerve block. The study also shows a similar short-term complication rate but a higher long-term complication rate than other studies. This data are important because it allows for an informed decision to be made between a surgeon, anesthesiologist, and the patient regarding the safety and necessity of delivering a preoperative peripheral nerve block based on patient risk factors.

Public Perceptions of Resuming Elective Surgery During the COVID-19 Pandemic

BackgroundMany U.S. health systems are grappling with how to safely resume elective surgery amid the COVID-19 pandemic. We used online crowdsourcing to explore public perceptions and concerns toward resuming elective surgery during the pandemic, and to determine factors associated with the preferred timing of surgery after health systems reopen. MethodsA 21-question survey was completed by 722 members of the public using Amazon Mechanical Turk. Multivariable logistic regression analysis was performed to determine factors associated with the timing of preferred surgery after health systems reopen. ResultsMost (61%) participants were concerned with contracting COVID-19 during the surgical process, primarily during check-in and in waiting room areas, as well as through excessive interactions with staff. Overall, 57% would choose to have their surgery at a hospital over an outpatient surgery center. About 1 in 4 (27%) would feel comfortable undergoing elective surgery in the first month of health systems reopening. After multivariable adjustment, native English speaking (OR, 2.6; 95% CI, 1.04-6.4; P = .042), male sex (OR, 1.9; 95% CI, 1.3-2.7; P < .001), and Veterans Affairs insurance (OR, 4.5; 95% CI, 1.1-18.7; P = .036) were independent predictors of preferring earlier surgery. ConclusionWomen and non-native English speakers may be more hesitant to undergo elective surgery amid the COVID-19 pandemic. Despite concerns of contagion, more than half of the public favors a hospital setting over an outpatient surgery center for their elective surgery. Concerted efforts to minimize patient congestion and unnecessary face-to-face interactions may prove most effective in reducing public anxiety and concerns over the safety of resuming elective care.

Infectious Flexor Tenosynovitis Following Trigger Finger Release: Incidence and Risk Factors.

Background: Trigger finger release (TFR) is one of the most commonly performed hand procedures and typically results in restoration of normal finger function. However, uncommon postoperative complications such as deep infection can have devastating consequences. The goal of this study was to evaluate the incidence, risk factors, and characteristics of infectious flexor tenosynovitis occurring after TFR. Methods: We searched billing records for the Current Procedural Terminology code for TFR to identify all adult patients who underwent TFR at our institution over a 10-year period. We defined infectious tenosynovitis as any case where the patient underwent tendon sheath drainage or postoperative wound debridement within 6 months of the index TFR procedure. Medical records were reviewed to obtain patient demographic information, body mass index (BMI), tobacco use, history of diabetes mellitus, surgical setting (clinic vs outpatient surgery center), and surgical digit for all patients. In those patients treated for infection, we recorded hospital length of stay, number of operative procedures, and any culture results. Results: We identified a total of 18 infections out of 2307 procedures (1827 patients), for an incidence of 0.99%. Current smokers had a significantly higher incidence of infection than nonsmokers (1.77% vs 0.29%). On univariate analysis, smoking was closely associated with infection (P ≤ .05). All infections occurred in overweight or obese patients by BMI criteria, but there was no difference in average BMI between patients with and without infection. History of diabetes, in-office surgery, patient age, and patient sex were not associated with a higher incidence of infection. Patients with infections spent an average of 4.1 days in the hospital, and 40% required multiple surgical procedures. The most common infectious organism cultured was Staphylococcus aureus, which was present in 67% of infections. Patients with isolated methicillin-sensitive S aureus on culture showed signs of infection within 3 weeks of the index procedure, whereas polymicrobial, coagulase-negative staphylococci or beta hemolytic streptococci were identified in patients presenting with infectious symptoms later. Conclusion: Infections after TFR are uncommon but are more likely to occur in patients who are current smokers and overweight or obese by BMI criteria. Methicillin-sensitive S aureus is the most likely causative organism, especially in patients presenting during the early postoperative course.

Measurement of Value in Anterior Cruciate Ligament Reconstruction: Patient-Level Value Analysis for the two-year Episode of Care

Objectives:Value-based payment models attempt to incentivize healthcare practices that reduce costs while improving patient outcomes. In order to optimize value, orthopaedic practices need a mechanism to quantify the value of the care that is provided to each individual patient. While this concept has been applied to total joint arthroplasty, sports has been largely excluded. Patient-level value-analysis (PLVA) defines value as a patient’s outcome achieved divided by the total cost of their episode of care. Measuring value on the patient-level allows a single number to describe value of the care received. The purpose of this study is to report PLVA and measure factors that influences the value of care delivered.Methods:All patients that underwent an ACL reconstruction for an acute ACL tear between the years of 2009 and 2016 at a single outpatient orthopaedic surgery center were identified via retrospective review of a prospectively collected patient-reported outcomes (PROs) registry. Patient demographics were collected via the electronic medical record (EMR) (Figure 2). The episode of care was defined as 2 years after surgery. The knee osteoarthritis outcomes score (KOOS) system was collected at initial preoperative baseline and two-years following surgery. The total cost-of-care was determined using time-driven activity-based-costing (TDABC). This formula derives the cost of care as a function of the time spent for each activity and personnel cost contributions for all involved. This process was performed at all phases: surgical intervention, all clinical follow-ups, and physical therapy (PT) sessions.Results:A total of 611 patients were included for this investigation. The patient sample was primarily female (n=355, 58.1%), average age of 28.9 + 12.9 [27.9, 30.0], and average BMI of 25.5 + 4.5 [25.2, 25.9]. A total of 151 (24.7%) patients were treated with an allograft with 128 (84.8%) utilizing a bone-patellar-bone (BTB) graft source. A total of 460 (75.3%) patients were treated with autograft with 272 (59.1%) utilizing a BTB graft source. The KOOS score was 65.3 + 15.9 [63.6, 66.9] at baseline and 83.2 + 13.5 [81.8, 84.6] at two-years, representing an improvement of 17.9 + 16.8 [16.2, 19.7]. There was a poor correlation between the change in two-year KOOS score and the TDABC cost-of-care (r=0.11). Autograft BTB demonstrated the highest overall value at two-years, 0.74 (ANOVA F: p<0.01), with an estimated 64.3% of patients falling in the “Above Average + Low Cost,” quadrant (Figure 1).Conclusion:This is the first study to apply PLVA methodology over the entire episode of care for ACL reconstructions. In our study, there was no correlation between an increased cost-of-care and an improvement in patient-reported outcomes. The autograft BTB demonstrated the greatest patient-level value within this cohort. With the growing focus of healthcare transitioning towards value-based delivery, PLVA offers orthopaedic practices and healthcare institutions a quantitative framework to evaluate the value of individual patient care delivery over the entire episode of care. This data can be utilized to drive physician behavior change, develop better care pathways, and optimize care delivery.Figure 1.Figure 2.

Does Graft type affect the Cost of Anterior Cruciate Ligament Reconstruction: A Time-Driven Activity-Based Costing Approach Comparing Hamstring and Bone Patella Bone Autograft

Objectives:Annually, an estimated 250,000 anterior cruciate ligament (ACL) reconstructions are performed. Operative management of ACL injuries has increased 22% between 2002 and 2014. With national healthcare expenditures rising at unsustainable rates, an improved understanding of healthcare costs is essential to identifying avenues of inefficiency and implement innovative solutions. This study is purposed to utilize time-driven activity-based costing (TDABC) to estimate the costs for the two-year care episode in the surgical reconstruction of ACL tears. Provided its high incidence, the operative reconstruction of ACL injuries serves as a prime setting for this study.Methods:This study follows 611 patients that underwent an ACL reconstruction for an acute ACL tear between 2009-2016 within a single outpatient orthopaedic surgery center (Figure 1). Patient demographics were collected via the electronic medical record (EMR) (Table 1). The total cost-of-care was determined using time-driven activity-based-costing (TDABC). This formula derives the cost of care as a function of the time spent for each activity and personnel cost contributions for all involved. This process was performed at all phases: surgical intervention, all clinical follow-ups, and physical therapy (PT) sessions.Results:A total of 611 patients were included for this investigation. The patient sample was primarily female (n=355, 58.1%) with an average age of 28.9 + 12.9 [27.9, 30.0], and average BMI of 25.5 + 4.5 [25.2, 25.9]. The majority of the patients identified with an Anesthesiologist Society of America (ASA) score of 1 (n=505, 83.9%). The average operative time was 107.1 + 31.5 minutes [104.6, 109.6]. The average TDABC cost-of-care was derived at $3364.95 + $958.99 [$3288.75, $3441.14]. Surgical costs occupied the greatest proportion of the overall cost-of-care, $1836.11 (53.2%), followed by costs relating to surgical implants, $911.61 (27.1%), physical therapy appointments, $342.00 (10.2%), and clinical follow-up appointments, $318.77 (9.5%) (Figure 1). A total of 459 (75.1%) patients were treated with an autograft, averaging a total cost-of-care of $2882.19, with the 90th percentile costing $3427.23 and 10th percentile costing $2343.08, reporting a 16.0% variability in costing. Of the 152 (24.9%) allografts, the average cost of care was $4884.10, with the 90th percentile costing $5321.50 and 10th percentile costing $4411.25, reporting a 9.0% variability. Hamstring autografts reported a significantly higher cost-of-care when compared to bone-patellar-bone (BTB) autografts (Hamstring: $3120.10 vs BTB: $2718.60; p<0.01).Conclusion:Given the increasing frequency of ACL procedures performed, an improved understanding of its costing components is critical for implementing change and strategizing solutions for increasing healthcare costs. Operative costs drive the total cost of care with implants, graft choice, and surgical resources constituting almost 80% for the two-year cost episode. With the growing focus of healthcare transitioning towards value-based healthcare delivery and cost reduction, identifying areas of costing inefficiency in surgical decision-making and implant-choice provides an avenue to reduce costs.Figure 1.Table 1.Population characteristics for study sample between 2009-2016 (N=611) n (% of N) or Mean SD (95% CI) GenderFemale: 355 (58.1%)Male: 256 (41.9%)Age28.912.9 (27.9, 30.0)BMI25.54.5 (25.2, 25.9)Anxiety105 (17.3%)Depression82 (13.5%)ASA1: 505 (83.9%)2: 92 (15.3%)3: 5 (0.8%)Operative Time (Minutes)107.131.5 (104.6, 109.6)Other Ligament TearLateral Collateral Ligament (LCL): 6 (1.0%)Medial Collateral Ligament (MCL): 30 (4.9%)Posterior Collateral Ligament (PCL): 3 (0.5%)Meniscus TearLateral: 213 (38.9%)Medial: 170 (31.1%)Meniscetomy188 (40.6%)Graft SourceAllograft: 151 (24.7%)Autograft: 460 (75.3%)Graft TypeBone-Patellar Tendon-Bone Graft (BTB): 400 (65.4%)Hamstring: 197 (32.2%)Posterior Tibialis: 9 (1.5%)Anterior Tibialis: 5 (0.8%)SANE @ BaselineSANE @ 1-YearSANE @ 2-Years63.423.3 (61.5, 65.4)88.412.7 (87.0, 89.9)85.622.4 (83.8, 87.5)SANE 1-Year24.122.8 (21.5, 26.7)SANE 2-Years22.929.3 (20.4, 25.4)KOOS @ BaselineKOOS @ 1-YearKOOS @ 2-Years65.315.9 (63.6, 66.9)79.712.7 (77.5, 81.9)83.213.5 (81.8, 84.6)KOOS 1-Year17.416.1 (14.6, 20.1)KOOS 2-Years17.916.8 (16.2, 19.7)Total Cost$3364.95958.99 ($3288.75, $3441.14)1-Year Value Coefficient ()0.550.53 (0.46, 0.64)2-Year Value Coefficient ()0.580.57 (0.52, 0.64)A Summary of the study populations’ characteristics

Current Trends in WALANT Surgery: A Survey of American Society for Surgery of the Hand Members

PurposeTo define self-reported WALANT use among American Society for Surgery of the Hand (ASSH) members. We aimed to define surgeon and practice demographics relative to WALANT use and identify potential barriers for WALANT implementation.MethodsAn anonymous multiple-choice survey was electronically distributed to all active ASSH members. Incomplete surveys were included in the final analysis. Surgeons were asked to provide reasons for not performing WALANT, which were categorized based on general themes. We compared practice and surgeon demographic information relative to WALANT use.ResultsOf 3,826 ASSH members, 869 responded (23%). A total of 79% of respondents had performed at least one WALANT procedure; 62% currently incorporated WALANT into their practice. Hospital-owned outpatient surgery centers were the most common location for WALANT procedures (31%). Canadian surgeons were more likely to use WALANT, compared with US and international surgeons. Surgeons with fewer years in practice and higher-volume surgeons were more likely to use WALANT. There was no statistically significant association between either practice or income structure and WALANT use. For carpal tunnel release (CTR), 13% did not offer patients WALANT, whereas 43% offered WALANT to all patients. Moreover, 51% of surgeons reported that anesthesia staff was required to be present for WALANT cases at their institution. In determining reasons for not using WALANT, 16% reported that they preferred a tourniquet for visualization. Only 2% had concerns regarding epinephrine use in the hand.ConclusionsThe results of this survey illustrate current WALANT use among ASSH members and defines the demographics of those employing WALANT. Lack of familiarity with WALANT and an acceptance of the use of epinephrine in the hand has increased from prior ASSH surveys. Lack of familiarity with the technique, concerns regarding operating room efficiency, and patient preferences remain considerable barriers to more widespread adoption of WALANT procedures.Type of study/level of evidenceEconomic and Decision Analysis V.

Gabapentin as an adjunct to paracervical block for perioperative pain management for first-trimester uterine aspiration: a randomized controlled trial

Pain management approaches during uterine aspiration vary, which include local anesthetic, oral analgesics, moderate sedation, deep sedation, or a combination of approaches. For local anesthetic approaches specifically, we continue to have suboptimal pain control. Gabapentin as an adjunct to pain management has proven to be beneficial in gynecologic surgery. We sought to evaluate the impact of gabapentin on perioperative pain during surgical management of first-trimester abortion or early pregnancy loss with uterine aspiration under local anesthesia. We hypothesized that adding gabapentin to local anesthesia will reduce perioperative and postoperative pain associated with uterine aspiration. Secondary outcomes included tolerability of gabapentin and postoperative pain, nausea, vomiting, and anxiety. We conducted a randomized double-blinded placebo-controlled trial of gabapentin 600 mg given 1 to 2 hours preoperatively among subjects receiving a first-trimester uterine aspiration under paracervical block in an outpatient ambulatory surgery center. There were 111 subjects randomized. The primary outcome was pain at time of uterine aspiration as measured on a 100-mm visual analog scale. Secondary outcomes included pain at other perioperative time points. To assess changes in pain measures, an intention to treat mixed effects model was fit with treatment groups (gabapentin vs control) as a between-subjects factor and time point as a within-subjects factor plus their interaction term. Because of a non-normal distribution of pain scores, the area under the curve was calculated for secondary outcomes with comparison of groups utilizing Mann-Whitney U tests. Among the 111 randomized, most subjects were Black or African American (69.4%), mean age was 26 years (±5.5), and mean gestational age was 61.3 days (standard deviation, 14.10). Mean pain scores at time of uterine aspiration were 66.77 (gabapentin) vs 71.06 (placebo), with a mean difference of-3.38 (P=.51). There were no significant changes in pain score preoperatively or intraoperatively. Subjects who received gabapentin had significantly lower levels of pain at 10 minutes after surgery (mean difference [standard error (SE)]=-13.0 [-5.0]; P=.01) and 30 minutes after surgery (mean difference [SE]=-10.8 [-5.1]; P=.03) compared with subjects who received placebo. Median nausea scores and incidence of emesis pre- and postoperatively did not differ between groups. Similarly, anxiety scores did not differ between groups, before or after the procedure. At 10 and 30 minutes after the procedure, most participants reported no side effects or mild side effects, and this did not differ between groups. Preoperative gabapentin did not reduce pain during uterine aspiration. However, it did reduce postoperative pain, which may prove to be a desired attribute of its use, particularly in cases where postoperative pain may be a greater challenge.

Abstract 101: Variation in Patient Characteristics and Outcomes Between Clinical Settings for Endovascular Femoropopliteal Artery Revascularization

Background: After CMS modified reimbursement rates for outpatient peripheral vascular intervention (PVI) in 2008, clinicians began to increasingly perform PVIs in hospital outpatient centers and ambulatory surgery centers (ASCs)/office-based laboratories (OBLs). Little is known about the characteristics of patients treated in freestanding ASCs/OBLs and their respective long-term outcomes compared to those treated in other settings. Methods: Medicare fee-for-service beneficiaries ≥66 years undergoing femoropopliteal artery PVI between 4/1/15-12/31/17 in ambulatory settings and 10/1/15-12/31/17 in inpatient centers were identified using carrier files linked to institutional outpatient files and MedPAR data. The vital status file was used to determine mortality through 4/30/19. Patients required ≥1 year of data prior to PVI to allow for ascertainment of comorbidities. An area deprivation index of ≤15 th percentile was used to identify those who reside in regions of lower socioeconomic status (SES). Results: Of 147,573 patients undergoing femoropopliteal PVI, 62,673 (42.5%) were treated as inpatients, 82,135 (55.7%) in hospital outpatient centers, and 2,765 (1.9%) in ASCs/OBLs. Patients treated in ASCs/OBLs had a greater burden of comorbidities, and were more likely to be Black (20.5% vs 11.6% outpt vs 14.1% inpt), dually-enrolled in Medicaid-Medicare (32.7% vs 18.5% outpt vs. 24.8% inpt), and reside in lower SES regions (44.8% vs 26.6% oupt vs 34.4% inpt). The unadjusted cumulative incidence of long-term mortality was similar between patients treated at ASCs/OBLs and inpatient centers, whereas hospital outpatients had higher survival (Figure 1). After adjusting for patient characteristics (demographics, comorbidities, and markers of SES), individuals treated in ASCs/OBLs had lower mortality rates than inpatient centers (HR 0.67, 95% CI 0.61-0.73) and attenuated mortality rates compared to outpatient centers (HR 1.10, 95% CI 1.01-1.20). Conclusions: Medicare beneficiaries undergoing femoropopliteal PVI at ASCs/OBLs are more socioeconomically disadvantaged and have a higher burden of comorbidities compared with other clinical settings. These differences in patient characteristics largely explain heterogeneity in long-term survival between facilities.

Guidelines for Ambulatory Surgery Centers for the Care of Surgically Necessary/Time-Sensitive Orthopaedic Cases During the COVID-19 Pandemic

Guidelines for Ambulatory Surgery Centers for the Care of Surgically Necessary/Time-Sensitive Orthopaedic Cases During the COVID-19 Pandemic

Disparities in Hip Arthroplasty Outcomes: Results of a Statewide Hospital Registry From 2016 to 2018

BackgroundIn November 2019, Centers for Medicare and Medicaid Services announced total hip arthroplasty (THA) will be removed from the inpatient-only list. This may lead to avoidance of patients who have prolonged hospitalizations and discharge to skilled nursing facilities or push providers to unsafely push patients to outpatient surgery centers. Disparities in hip arthroplasty may worsen as patients are “risk stratified” preoperatively to minimize cost outliers. We aimed to evaluate which patient characteristics are associated with extended length of stay (eLOS)—greater than 2 days—and nonhome discharge in patients undergoing hip arthroplasty. MethodsThe Illinois COMPdata administrative database was queried for THA admissions from January 2016 to June 2018. Variables included age, sex, race and ethnicity, median household income, Illinois region, insurance status, principal diagnosis, Charlson comorbidity index, obesity, discharge disposition, and LOS. Hospital characteristics included bundled payment participation and arthroplasty volume. Using multiple Poisson regression, we examined the association between these factors and the likelihood of nonhome discharge and eLOS. ResultsThere were 41,832 THA admissions from January 2016 to June 2018. A total of 36% had LOS greater than 2 midnights and 25.3% of patients had nonhome discharges. Female patients, non-Hispanic black patients, patients older than 75, obese patients, Medicaid or uninsured status, Charlson comorbidity index > 3, and hip arthroplasty for fracture were associated with increased risk of eLOS and/or nonhome discharge (P < .05). ConclusionWith the Centers for Medicare and Medicaid Services emphasis on cost containment, patients at risk of extended stay or nonhome discharge may be deemed “high risk” and have difficulty accessing arthroplasty care. These are potentially vulnerable groups during the transition to the bundled payment model.