Outpatient Surgical Center Research Articles

What's New in Spine Surgery.

What's New in Spine Surgery.

Raymond A Dieter, Jr. MD MS

Raymond A Dieter, Jr. MD MS

Optimizing Tourniquet Pressure in Upper Extremity Surgery.

Background: Pneumatic tourniquet is an effective tool to achieve hemostatic control of the surgical field in upper extremity (UE) operations. Elevated pressures have been associated with adverse effects despite various methods of pressure determination. We aim to demonstrate the usage of reduced tourniquet pressures and examine factors associated with achieving reduced pressures. Methods: A prospective study was conducted (2016-2018) at a Level 1 Trauma Center and an Outpatient Surgical Center, totaling 226 operations, involving a reduction of cuff pressures over time from a standard baseline of limb occlusion pressure for UE operations. Results: A gradual reduction of pressures was successfully achieved with a mean pressure of 187 mmHg and average time of tourniquet application being 25 minutes. We found chronological surgical number and patient BMI to be significantly associated with tourniquet pressure (p < 0.05). 4.5% of cases resulted in breakthrough bleeding, but did not reliably occur with any pressure thresholds, patient demographics, or operative factors (p > 0.05, for all). Conclusions: Reduced tourniquet pressures can mitigate complications associated with tourniquet use. Our research shows reduced pressures are successful in maintaining field visibility and we encourage an adoption of pressures below 200 mm Hg in most procedures that require a tourniquet.

Sutureless Transconjunctival Insertion of Eyelid Weights: A Novel Technique.

To describe a novel surgical technique for implanting eyelid weights via a sutureless transconjunctival approach. In comparison to the traditional supratarsal crease approach, this technique does not involve any external incisions or suture placement. The procedure can reduce surgical time and complications associated with the traditional external approach. This case series includes 13 patients who underwent eyelid weight placement via the transconjunctival approach for paralytic lagophthalmos secondary to facial nerve paralysis (12 patients had unilateral paralysis and 1 patient had bilateral) with a total of 14 eyelid weights placed. The procedures were performed at an outpatient office-based surgical center. All procedures were performed or supervised by the same surgeon. Patients were followed for an average 6-month postoperative period for postoperative complications. The sutureless transconjunctival approach to eyelid weight insertion was successful in achieving the desired functional and aesthetic outcomes. Patients undergoing this technique avoided the discomfort of postoperative suture removal. All patients achieved comparable outcomes postoperatively. There were no complications reported across the 13 patients throughout the 6-month postoperative period. This case series demonstrates that the transconjunctival approach for metal eyelid weight insertion is practical, relatively easy to perform, and associated with functional outcomes that are comparable to those achieved with the traditional approach, however, without external incision or placement of sutures.

Complicated Hysteroscopic Removal of Retained IUD Fragment

<h3>Study Objective</h3> Demonstrate successful complicated hysteroscopic removal of retained Paragard IUD arm after prior attempts, highlight role of diagnostic imaging prior to the case, and emphasize entry and surgical technique to optimize successful removal. <h3>Design</h3> Case report. <h3>Setting</h3> Outpatient surgical center. <h3>Patients or Participants</h3> Single patient. <h3>Interventions</h3> In-office ultrasound, subsequent hysteroscopy. <h3>Measurements and Main Results</h3> Successful removal of retained fragment. <h3>Conclusion</h3> In a patient with prior failed attempts, imaging (particularly surgeon in-office ultrasound prior to hysteroscopy) in combination with good hysteroscopic practice pearls contribute to a successful complicated removal of a retained IUD fragment.

Sustainability Initiatives in the Operating Room.

Operating rooms (ORs) contribute up to 30% of a hospital's waste, are very resource-intensive, and thus provide an opportunity for improvement. A narrative review was conducted, searching MEDLINE, EMBASE, and ProQuest databases. The study included 78 of the 108 published articles. The researchers identified and categorized articles according to the following major themes: Committee and Leadership; Waste Reduction; Segregating OR waste; Minimizing unnecessary devices and packaging; Reducing energy consumption; Choosing anesthetic gases; Education; Reducing water consumption; Different surgical venues; Donating medical supplies. Formation of an OR committee or a hospital Green Team dedicated to environmentally sustainable initiatives can significantly improve health care's impact on the environment while saving money. Changes in supply chain with preferences for reusable devices, effective recycling, repurposing instruments, and donating items can all be effective means of diverting waste away from landfills. Reducing unnecessary packaging and instruments would eliminate excess in the waste stream. Curtailing energy and water usage results in cost and environmental savings. Surgical venue (inpatient vs. outpatient surgical center) can also contribute to waste. Transitioning away from certain inhaled anesthetics can minimize greenhouse gas impact. Education to all levels in the health care system is important to drive change and maintain change. Optimizing efficiency and decreasing waste generation can have a positive impact on the environment and can be accompanied by cost reduction. Because the field of sustainability in health care is young but burgeoning, increased research is needed to support evidence-based approaches.

Improving environmental sustainability in outpatient clinics: Lessons from a waste audit

BackgroundThe healthcare industry is the second leading contributor of waste in the United States. While there are multiple examples of medical waste audits in the literature, few were conducted in outpatient settings. The objective of this study was to utilize a waste audit to identify key waste generators in an outpatient practice and start immediately reducing waste and greenhouse gas emissions. Materials and methodsThis was a cross-sectional, observational study wherein waste from a total of 31 randomly selected encounters from December 2020 through June 2021 in the Physical Medicine & Rehabilitation Sports and Spine clinics of an academic center was collected and weighed, and key waste generators were identified. ResultsThe outpatient surgical center produced the most waste per patient encounter (1,758 g), followed by in-clinic procedure visits (379 g per encounter). Clinicians who performed in-clinic procedures using pre-packaged procedure kits produced an estimated 819.5 kg more waste annually than those who selected individual sterile components for their procedures. DiscussionBy identifying and developing interventions that target key waste generators, such as reducing the use of pre-packaged injection kits, we demonstrate how outpatient offices can immediately reduce waste. In doing so, we demonstrate the significant potential environmental savings of such measures.

Viable Disc Tissue Allograft Supplementation; One- and Two-level Treatment of Degenerated Intervertebral Discs in Patients with Chronic Discogenic Low Back Pain: One Year Results of the VAST Randomized Controlled Trial

Background: A viable disc tissue allograft has been developed to supplement tissue loss associated with degenerative lumbar disc disease and the development of chronic discogenic lower back pain. Objectives: Viable disc allograft was injected into painful degenerated discs to evaluate safety and determine whether it can improve pain and function. Study Design: Patients received an active treatment of allograft or saline, or continued with nonsurgical management (NSM). Prior to entering the study, patients had back pain for a minimum of 6 months before treatment that was recalcitrant to nonoperative treatment modalities. Standardized outcome measures were used to evaluate the patient’s condition before and after treatment. Primary endpoints included improvement in Oswestry Disability Index (ODI) and Visual Analog Scale of Pain Intensity (VASPI). Conventional radiographs and magnetic resonance imaging scans were used to assess disc space height and spinal alignment, and to determine the degree of disc degeneration. Patients were followed for one year after enrollment. The NSM group could cross over to the allograft group after 3 months. Setting: This multicenter trial was completed in outpatient surgical centers and office injection suites. A total of 218 patients with chronic low back pain secondary to single-level or 2-level degenerative disc disease were enrolled. Inclusion criteria included pretreatment VASPI &gt;= 40 mm, ODI score &gt;= 40 and symptoms present longer than 6 months. Patients were blinded and randomized to receive intradiscal injections of either viable disc allograft or saline. Patients randomized to the NSM group continued existing treatment. Patients were assessed at 6 and 12 months. Adverse events (AEs) were continually assessed. Methods: The VAST trial is a prospective, multicenter, blind, randomized clinical trial (RCT) for patients with single-level or 2-level degenerative lumbar disc disease. Results: At 12 months, clinically meaningful improvements in mean VASPI and ODI scores were achieved in the investigational allograft and saline groups. A responder analysis demonstrated a clinically meaningful reduction in ODI of &gt;= 15 points at 12 months that was statistically significant; 76.5% of patients randomized to allograft were responders (P = 0.03) compared to 56.7% in the saline group. A responder group characterized by a ? 20 point reduction in pain at 12 months achieved a statistically significant reduction in pain compared to the saline group (P = 0.022). In the allograft group, 11 safety adverse events occurred in 141 patients (3.5%) and there were no persistently symptomatic AEs. Limitations: Limitations of this study include a comparison to saline that has been shown to be more representative of an active comparator as opposed to a placebo. In addition, 36 patients were lost to follow-up; this loss resulted in the saline and NSM/crossover groups being smaller than the predetermined group size to have an appropriately powered analysis. Conclusions: This large, prospective blinded RCT demonstrated safety and efficacy results indicating that viable disc tissue allograft may be a beneficial nonsurgical treatment for patients who have chronically painful lumbar degenerative discs. Further studies would be optimal to confirm efficacy Key words: Viable disc tissue allograft, discogenic back pain, allograft supplementation, degenerative disc disease, low back pain, intervertebral disc, intradiscal injection

The Utilization of an Opioid-Free Anesthetic for Pediatric Circumcision in an Ambulatory Surgery Center.

Circumcision is one of the most common urologic procedures performed at pediatric ambulatory centers. Emerging data on the short- and long-term effects of perioperative opioid administration has highlighted the importance of an opioid-free anesthetic regimen. We sought to evaluate the effectiveness of an opioid-free anesthetic in pediatric circumcision and its correlation with ambulatory surgery center efficiency. Patients, 3 years of age and younger, who underwent circumcision or circumcision revision by two surgeons pre and post introduction of an opioid-free anesthetic fast-track regimen at an outpatient surgical center were included. There were 100 patients included in this analysis, with 50 patients in each cohort. On univariate analysis, fast-tracking was associated with a decrease in median combined in-room and post-anesthesia care unit times (102.5 vs. 129.0 min, p-value < 0.001). This difference continued after multivariable analysis with an adjusted median combined in-room and post-anesthesia care unit time difference of −15.6 min (95% CI −34.2 to −12.7 min, p-value 0.018). In addition, the fast-track cohort received less intraoperative morphine equivalents without an increase in post-operative analgesic administration or change in postoperative questionnaire score. This demonstrates that opioid-free anesthesia may be used effectively in pediatric circumcision while also allowing for significant time savings for surgical centers.

A Qualitative Study of the Barriers and Benefits to Resident Education in Ambulatory Surgical Centers

As Ambulatory Surgical Centers (ASCs) become more common in academic medical centers, large hospital systems must determine how to shift resident education from inpatient to outpatient surgical centers. This study aims to define stakeholders' views regarding the integration of surgical residents into ASCs. Long-form interviews lasting 30 to 60 minutes were conducted. Interviews were hand-transcribed and analyzed by qualitative analysis to determine benefits of learning in ASCs for residents, challenges that arise from integrating residents, and recommendations to improve resident incorporation. Interviews were conducted using a video conferencing platform. Residency program directors, attending surgeons, graduate medical learners, and a nursing manager were interviewed. Twenty-one total interviews were conducted, representing ten different departments. Stakeholders agreed that residents benefit from being placed in ASCs because the fast, surgical pace allows the residents to engage in more cases. However, different stakeholders highlighted different challenges, all centered around the notion of inter-stakeholder conflict due to conflicting priorities among residents, attending physicians, and administration. Likewise, recommendations differed by stakeholder group-faculty members sought more defined learning objectives and enhanced communication, whereas residents desired that ambulatory surgical time be more structured. Despite the pressures of rapid case turnover, stakeholders agreed that there are many benefits to resident education in ASCs. Findings related to challenges and recommendations support the need to strengthen communication between stakeholder groups and better plan for resident integration into ASCs.

No Patients Having Elective Outpatient Orthopaedic Surgery Performed in an Ambulatory Surgery Center Using Preoperative Screening Protocols During the Coronavirus Pandemic Developed COVID-19

PurposeThe purpose of this study is to determine the safety of elective, outpatient orthopaedic sports procedures during the Coronavirus (COVID-19) pandemic at a high-volume orthopaedic practice.MethodsAll patients who were scheduled for elective, outpatient orthopaedic sports medicine procedures at 1 of 2 of outpatient surgical centers between July 1, 2020, and December 31, 2020, were asked to complete a custom survey during a postoperative clinic visit or phone call at a minimum of 2 weeks or were subject to a routine screening questionnaire and temperature screening at the time of the first postoperative follow-up visit. The survey questionnaire assessed for any COVID-19-related symptoms. Surgical case logs were retrieved to review for any cancelled surgeries due to a positive preoperative COVID-19 test.ResultsIn total, 3.5% of patients (n = 39/1119) scheduled for surgery were diagnosed with COVID-19 during preoperative testing, resulting in surgical cancellation. Patients with a positive preoperative COVID-19 test result were found to be significantly younger (46 ± 20 years) when compared to all other patients with a negative test (51 ± 21 years; P = .002). No patient was diagnosed with COVID-19, reported symptoms concerning for COVID infection, underwent additional testing, or reported close contact with another individual with a positive test or possessed symptoms concerning for COVID-19 at a minimum of 2 weeks after surgery.ConclusionThis study found that 3.5% of patients tested positive for COVID-19 and were significantly younger when compared with patients testing negative. No patient investigated for potential infection after surgery reported the development of any symptoms related to COVID-19 or reported a positive test result after surgery. Using current protocols for preoperative screening, elective outpatient orthopaedic surgery performed in an Ambulatory Surgical Center is safe with no documented cases of COVID-19 transmission in this cohort.Level of EvidenceLevel IV, prognostic case series.

Post-operative Opioid, Benzodiazepine and Sedative Usage in Medicare versus Commercial Insurance Hand Surgery Patients.

Opioid usage has increased in recent years. The purpose of this study is to assess post-operative opioid, sedative, and benzodiazepine usage in a Medicare population. Consecutive patients undergoing elbow, wrist, and hand surgery by hand surgeons at one academic outpatient surgical center were prospectively enrolled. Patients were excluded if they were minors or if they underwent more than one surgical procedure during the study period. There were 269 patients enrolled, and this group was divided by insurance type into younger commercial insurance (CI) and older Medicare (MC) groups. The Pennsylvania Physician Drug Monitoring Program website was used to document all prescriptions of controlled substances filled six months prior to and after the surgical procedure. The mean age in the CI group was 45.8 years (range: 16-88) and 69.2 years (range: 43-91) in the MC group. Postoperatively, the CI patients filled significantly less opioid prescriptions than the MC group, 1.10 vs. 1.79. Patients in the CI group were given an average of 0.3 benzodiazepine prescriptions before surgery and 0.2 after surgery. Patients in the MC group were given 0.6 prescriptions before and 0.5 prescriptions of benzodiazepines after surgery. The CI group was given an average of 0.1 sedative/hypnotic prescriptions before surgery and 0.1 after surgery. The MC group was given 0.7 prescriptions before and 0.4 prescriptions of sedative/hypnotics after surgery.There were 0.17 prescriptions per patient in the CI group and 0.75 per patient in the MC group (P <.05). Twenty-two of 208 (10.6%) of CI and 16/61 (26.2%) of MC patients filled a prescription between 3-8 months post-operatively. Prolonged use of opioid, benzodiazepine and sedative medications is common after upper extremity surgical procedures. Older patients are also at risk, and may be even more likely than younger patients to use these medications post-operatively.

Operating On a Stretcher Is a Safe Alternative to an Operating Room Table

Purpose: The primary purpose of this study was to compare intraoperative and post-operative complication rates for upper extremity surgical cases performed on a standard operating room (OR) table with similar cases done on a typical hospital stretcher. Secondary measures reviewed included surgical time, turnover time, total OR time, blood loss, tourniquet time, and postoperative complications. Methods: Using our institution’s electronic medical record system, we reviewed 100 consecutive upper extremity cases performed on a stretcher as well as 100 consecutive upper extremity cases done on a standard OR table. All cases were performed by the same board certified, fellowship trained orthopaedic surgeon. The cases were performed between February of 2014 and May of 2016 at a level one trauma center and its associated outpatient surgical center. Basic univariate statistical analyses were performed, and the two groups were compared for primary and secondary outcome measures. Results: The data showed no significant increase in intraoperative complication rates when operating on a standard hospital stretcher compared to operating on an OR table. There were a total of 6 postoperative complications in the stretcher group and a total of 11 complications in the OR table group. The most common postoperative complication seen in both cohorts was infection. There was one intraoperative complication in the OR table group and none in the stretcher group. With regard to total operating room time, surgical time, and delta time (overall OR room time minus surgical time which was used to calculate the turnover time), we found that the OR table group had shorter times in each category. The total OR time for the OR table group was a mean time of 105 minutes compared to 146 minutes seen in the stretcher group (p= 0.0002). Similarly, there was a shorter mean surgical time for surgeries done on an OR table (73 minutes) when compared to surgeries done on a stretcher (104 minutes) (p = 0.0026). Finally, the average turnover time (delta time) for the OR table group was 32 minutes while the average turnover time for the stretcher group was 42 minutes (p= 0.0002). The average tourniquet time for the OR table group was 36 minutes as compared to 41 in the stretcher group (p=0.467). Conclusion: Operating on a typical hospital stretcher is a safe alternative to operating on a standard operating room table as there was no increased complication rate seen with surgeries performed on a stretcher compared to an OR table.

Confirming Proper Button Deployment of Suspensory Fixation During ACL Reconstruction.

Background:Suspensory fixation of anterior cruciate ligament (ACL) reconstruction (ACLR) grafts has emerged as a popular device for femoral graft fixation. However, improper deployment of the suspensory fixation can compromise proper graft tensioning, leading to failure and revision. Also, soft tissue interposition between the button and bone has been associated with graft migration and pain, occasionally requiring revision surgery. Many surgeons rely on manual testing and application of distal tension to the graft to confirm proper button deployment on the lateral cortex of the femur for ACL graft fixation.Purpose:To determine the reliability of the manual resistance maneuver when applying distal tension to deploy the suspensory device along the lateral cortex of the femur.Study Design:Case series; Level of evidence, 4.Methods:All patients undergoing ACLR with a suture button suspensory device for femoral fixation were eligible for enrollment in the study. The surgeries were performed by 3 board-certified, sports medicine fellowship–trained orthopaedic surgeons at a single outpatient surgical center between May 2018 and June 2019. All grafts were passed in a retrograde manner into the femoral tunnel, and a vigorous manual tensioning maneuver in a distal direction was placed on the graft to deploy and secure along the lateral cortex of the femur. Intraoperative mini c-arm fluoroscopy was obtained to demonstrate proper suture button positioning. If interposing tissue or an improperly flipped button was identified, rectifying steps were undertaken and recorded.Results:A total of 51 patients with a mean age of 33.3 years were included in the study. Of these patients, 74.5% had normal suture button positioning identified via intraoperative fluoroscopic imaging, while 15.7% had interposed soft tissue and 9.8% had an improperly flipped button. In all cases, the surgeon was able to rectify the malpositioning intraoperatively.Conclusion:Despite the manual sensation of proper suspensory button positioning, intraoperative fluoroscopy identified suture button deployment errors in ACLR 25% of the time. Correcting the malpositioning is not technically demanding. These findings advocate for routine intraoperative surveillance to confirm appropriate suture button seating during ACLR.

Trends in the Surgical Treatment of Pseudotumor Cerebri Syndrome in the United States

Optic nerve sheath fenestration (ONSF) and cerebrospinal fluid shunting are sometimes used to treat pseudotumor cerebri syndrome (PTCS), but their use patterns are unknown. To investigate the frequency of surgical PTCS treatment in the United States and to compare patients undergoing ONSF with those treated with shunting. This was a retrospective longitudinal cross-sectional study. Inpatient data were obtained from the National Inpatient Sample (NIS), and outpatient surgical center data were obtained from the National Survey of Ambulatory Surgery (NSAS) and National Hospital Ambulatory Medical Care Survey (NHAMCS). Included in the analysis were 10 720 patients aged 18 to 65 years with a diagnosis code for PTCS, excluding venous thrombosis and other causes of intracranial hypertension. Time trends were explored and logistic regression was used to measure differences according to age, race/ethnicity, sex, Elixhauser comorbidity index, and other patient and hospital characteristics. Data analysis was performed from March 31 to October 7, 2020. Treatment for PTCS, excluding venous thrombosis and other causes of intracranial hypertension. Annual number of PTCS-related admissions, ONSFs, and shunt procedures from 2002-2016. Patient and hospital-level characteristics of patients with PTCS undergoing ONSF or shunting were compared. Between 2010 and 2016, 297 ONSFs were performed and 10 423 shunts were placed as treatment for PTCS. The procedures were most commonly performed in individuals aged 26 to 35 years (39.4%), and 9920 (92.4%) of the surgically treated patients were women. ONSF was more common among younger patients (eg, adjusted odds ratio [AOR] for patients ≥46 years vs those 18-25 years, 0.22; 95% CI, 0.08-0.61) and in Black, Hispanic, or other minority populations (AOR, 2.37; 95% CI, 1.31-4.30) and less common in the South (AOR, 0.34; 95% CI, 0.13-0.88) and West (AOR, 0.15; 95% CI, 0.04-0.58) compared with the Northeast. Total PTCS-related hospitalizations increased from 6081 (95% CI, 5137-7025) in 2002 to 18 020 (95% CI, 16 607-19 433) in 2016. Shunting increased from 2002 to 2011 and subsequently plateaued and declined. ONSF was used much less frequently, and use has not increased. No instances of outpatient ONSF or shunting for PTCS were recorded in the NSAS or NHAMCS databases. This study's findings suggest that shunting is more common than ONSF and that the use gap has widened as shunting has increased. However, because overall PTCS-related hospitalizations have increased even more rapidly, the percentage of inpatients with PTCS undergoing surgery has decreased. These trends may reflect changes in medical treatment practices and outcomes or growing limitations in access to ophthalmic surgical expertise.

Demand for Surgical Procedures Following COVID-19: The Need for Operational Strategies That Optimize Resource Utilization and Value.

Demand for Surgical Procedures Following COVID-19: The Need for Operational Strategies That Optimize Resource Utilization and Value.

S0335 Colorectal Cancer Screening Gender and Race Disparities in Western PA … Is There Really a Difference?

INTRODUCTION: The American College of Gastroenterology advocates that colorectal cancer screening should start earlier in African Americans because of the higher incidence and more aggressive nature in this population. We aimed to address colonoscopy screening disparities among the different races and genders investigating valuable significant contributors. METHODS: We reviewed GIQuIC data from 3 hospitals and 5 endoscopy outpatient surgical centers from October 2018 to December 2019. An analysis was created utilizing Highmark Health claims and the US Census Bureau American Community Survey data showing the strongest correlation for a lack of colorectal cancer screening by race and lower socioeconomic status (Figure 1). Through utilization of this data and GIQuIC data, we analyzed race and age of colorectal cancer screenings among African American and Caucasians. RESULTS: Among all screening colonoscopies available in the GIQuIC data, 84.1% constituted whites and 11.5% constituted African Americans (P < 0.0001) which is consistent with the low rate of African American screenings in the census data. Of all screenings, 54.7% were females and 45.3% males (P < 0.0001). We further looked at the data by race and gender (Table 1) and screening rates by age group (Table 2). Whites had screenings at age 50 more often than age appropriate screening for African Americans (age 45). Interestingly, colonoscopy prep quality was the lowest in black males, while it was the highest for white females. CONCLUSION: We found that African Americans are less likely than Caucasians to have screening tests for colorectal cancer in our region. This is consistent with previous studies. This may be due to lower socioeconomic status, lack of access in underserved areas, and lack of awareness/education. Better resources are required to educate the African American population regarding timely colonoscopy screening at age 45, colonoscopy prep instruction, and identifying barriers to access as key indicators to improve screening overall. We plan to target the underserved areas in the near future to improve CRC screening in the African American population. There was also an overwhelmingly higher number of females screened when compared to males. Is it because males are more apprehensive about colonoscopy? Further studies are needed to investigate such findings.Figure 1.: US Census Bureau American Community Survey data.Table 1.: Race and Gender.Table 2.: Screening Rates by Age Range.

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. . . .

150. Outpatient vs inpatient anterior lumbar surgery: a multisite, comparative analysis of patient safety measures

BACKGROUND CONTEXT The frequency and complexity of spinal surgery performed in an outpatient setting has been steadily increasing in the past decade. However, data on the safety and efficacy of most spinal procedures adapted to the outpatient setting is lacking. The few studies that have reviewed specific outpatient procedures have mostly focused on anterior cervical surgery, and have drawn conflicting conclusions. To our knowledge, there is no published literature on the feasibility, safety and effectiveness of anterior lumbar surgery (fusions and disc replacements) in an outpatient setting. PURPOSE The purpose of this study is to evaluate the safety and efficacy of outpatient anterior lumbar procedures compared to procedures done at an inpatient setting in a matched cohort of patients. STUDY DESIGN/SETTING This study is a retrospective matched cohort study of patients who underwent an anterior lumbar interbody fusion (ALIF) or a lumbar artificial disc replacement (LADR) at an inpatient facility, compared to a free-standing ambulatory surgery center. PATIENT SAMPLE Consecutive adult patients of several orthopedic and neurosurgical spine surgeons, who underwent elective stand-alone ALIF or LADR or a hybrid of fusion and disc replacement, at either an inpatient tertiary care facility or an outpatient surgical center were studied. A minimum of 90-day follow-up was required. OUTCOME MEASURES Reoperation rates, readmission rates, 90-day complication rates, and length-of-stay data were collected and compared between the two groups. Complications that were specifically assessed included neurological injury, durotomy, vascular injuries, bowel injuries, postoperative ileus, epidural or retroperitoneal hematomas, postoperative urinary retention, urinary tract infections, deep vein thrombosis (DVT), pulmonary embolism (PE), cardio-pulmonary complications, intractable pain, surgical site infection, and death. METHODS Medical records of 231 consecutive patients who underwent ALIF or LADR procedures between 2016-2019 were reviewed. The inpatient and outpatient cohorts were matched with regards to age, sex, body mass index (BMI), and medical comorbidities. Length of stay, complication data, reoperations, and readmissions were recorded and compared between the groups. RESULTS A total of 124 (54%) inpatient and 107 (46%) outpatient patients were reviewed for this study. The two groups had similar baseline characteristics. While there was a trend toward fewer complications, reoperations and readmission for the outpatient cohort, the differences were not statistically significant. The overall 90-day complication rate was 5.6% for the inpatient cohort, and 0.9% for the outpatient cohort. Of the patients in the inpatient cohort, 3.2% were re-admitted within 90 days, compared to 1.9% of those in the outpatient cohort. Reoperation rate was 1.6% for the inpatient cohort. No patient from the outpatient cohort required reoperation. The average hospital stay was 56.9 hours, compared to 5.2 hours at the ambulatory surgery center. CONCLUSIONS There were no statistically significant differences between the 90-day complication and reoperation rates between anterior lumbar procedures performed in an inpatient vs outpatient setting in a matched cohort of patients. Furthermore, the overall 90-day readmission rates were lower for outpatients than for inpatients. Our results support the conclusion that anterior lumbar procedures including 1- and 2-level ALIF and LADR procedures can be performed safely in an outpatient setting. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Association Between Medicaid Expansion and the Use of Outpatient General Surgical Care Among US Adults in Multiple States

The Affordable Care Act expanded access to Medicaid coverage in 2014 for individuals living in participating states. Whether expanded coverage was associated with increases in the use of outpatient surgical care, particularly among underserved populations, remains unknown. To evaluate the association between state participation in the Affordable Care Act Medicaid expansion reform and the use of outpatient surgical care. This case-control study used a quasi-experimental difference-in-differences design to compare the use of outpatient surgical care at the facility and state levels by patient demographic characteristics and payer categories (Medicaid, private insurance, and no insurance). Data from 2013 (before Medicaid expansion reform) and 2015 (after Medicaid expansion reform) were obtained from the State Ambulatory Surgery and Services Database of the Healthcare Cost and Utilization Project. The absolute and mean numbers of procedures performed at outpatient surgical centers in 2 states (Michigan and New York) that participated in Medicaid expansion (expansion states) were compared with those performed at outpatient surgical centers in 2 states (Florida and North Carolina) that did not participate in Medicaid expansion (nonexpansion states). The population-based sample included 207 176 patients aged 18 to 64 years who received 4 common outpatient procedures (laparoscopic cholecystectomy, breast lumpectomy, open inguinal hernia repair, and laparoscopic inguinal hernia repair). Data were analyzed from May 19 to August 25, 2019. State variation in the adoption of Medicaid expansion before and after expansion reform was implemented through the Affordable Care Act. Changes in the mean number of procedures performed at the facility level before and after Medicaid expansion reform in states with and without expanded Medicaid coverage. A total of 207 176 patients (106 395 women [51.35%] and 100 781 men [48.65%]; mean [SD] age, 45.7 [12.4] years) were included in the sample. Overall, 116 752 procedures were performed in Medicaid expansion states and 90 424 procedures in nonexpansion states. A 9.8% increase (95% CI, 0.4%-20.0%; P = .04) in cholecystectomies, a 26.1% increase (95% CI, 9.8%-44.7%; P = .001) in lumpectomies, and a 16.3% increase (95% CI, 2.9%-31.5%; P = .02) in laparoscopic inguinal hernia repairs were observed at the facility level in expansion states compared with nonexpansion states. Among patients with Medicaid coverage, the mean number of procedures performed in all 4 procedure categories increased between 60.5% (95% CI, 24.7%-106.6%; P < .001) and 79.2% (95% CI, 53.5%-109.2%; P < .001) at the facility level. The increases in the number of Medicaid patients who received treatment exceeded the reductions in the number of uninsured patients who received treatment with laparoscopic cholecystectomy, open inguinal hernia repair, and laparoscopic inguinal hernia repairs in expansion states compared with nonexpansion states. Black patients received more laparoscopic cholecystectomies, lumpectomies, and open inguinal hernia repairs in expansion states than in nonexpansion states. Study results suggest that Medicaid expansion was associated with increases in the use of outpatient surgical care in states that participated in Medicaid expansion. Most of this increase represented patients who were newly treated rather than patients who converted from no insurance to Medicaid coverage.