Pat Bovonratwet, MD, was recruited to Boston-based Massachusetts General Hospital to build out its minimally invasive and endoscopic spine program. Now that the program has been established, the department is setting its sights on the outpatient shift.
He began operating at the system’s freestanding, hospital-owned surgery center in January, initially about one day per month. He is now there almost weekly, doing an average of three to four cases a day, and is approaching 50 cases at the center with no readmissions or transfers.
The shift reflects a growing recognition among large academic systems that high-volume procedures benefit from dedicated, consistent teams, Dr. Bovonratwet told Becker’s. He credited his chair and chief with seeing where the specialty was headed.
“There are 90 operating rooms on Mass General’s main campus, and they do everything from xenotransplantation to brain surgery,” he said. “Every scrub tech, every member of the OR staff, has to be ready for anything. Getting the same team consistently for these high-volume procedures sometimes just isn’t possible.”
Efficiency tends to improve with consistent teams, he said, and that was the push behind the program. Healthcare resource utilization was the other driver.
“Improving healthcare utilization is about matching patients to the appropriate level of care. Our ambulatory spine program allows us to shift appropriate cases to the outpatient setting while preserving Mass General’s tertiary-level resources for patients who need them most,” he said.
Winning over the surgery center
Because the surgery center is owned by the hospital rather than physicians, moving cases out of the main campus didn’t set up a turf battle between the ASC and the hospital. The bigger hurdle was cultural. When Dr. Bovonratwet, who completed part of his training at Hospital for Special Surgery in New York City, first proposed the move, the center’s leadership had some concerns about the postoperative care of spine surgery patients in the ASC setting.
“I had to explain that these modern endoscopic techniques allow for rapid recovery because they minimize soft-tissue disruption and allow patients to ambulate independently after surgery,” he said.
The setup has proven popular with patients, too. “Patients often find it more convenient to have surgery at the ambulatory surgery center because of its proximity to where they live, which can improve access to these modern minimally invasive techniques,” he said.
With the program nearing 50 cases at the freestanding center without a readmission or transfer, leadership support for expanding the service line is growing, he added.
Choosing who goes outpatient
Age alone doesn’t determine whether a patient is a candidate for the surgery center, Dr. Bovonratwet said. Some 75- and 80-year-olds are very fit and healthy. He weighs comorbidity burden, whether patients have help at home and their social circumstances.
A patient close to 80 who lives alone is more likely to have surgery at the hospital so that visiting nurses can be arranged. Some otherwise healthy patients, such as young mothers with children at home, ask to recover overnight in the hospital.
He performs tubular, uniportal and biportal endoscopic procedures and matches the technique to the pathology. Foraminal and far lateral disc herniations are where endoscopy shines, he said, because no open alternative offers the same access with as little disruption to surrounding native tissues. He still performs open procedures when they’re indicated.
“Endoscopic spine surgery is just part of the toolbox,” he said. “You pick and choose.”
Training and cost
Dr. Bovonratwet said many of the field’s first endoscopic spine surgeons did not have the luxury of being exposed to these techniques during formal residency training, something that is now changing. Dr. Bovonratwet had exposure during residency and supplemented it with a traveling clinical fellowship in South Korea, which he said helped tremendously with the learning curve. He now trains residents and fellows.
He agrees with those who say programs without endoscopic capabilities risk falling behind. “If a large training institution does not have anyone doing this, then it’s just part of the toolbox that the trainee is missing,” he said.
Equipment costs are less of a barrier at a large academic medical center, he said, but device companies increasingly recognize that upfront capital purchases block adoption, especially at independent practices. Many now offer loaner or lease-to-buy arrangements. For programs looking to test the waters, he said, those options make sense before investing heavily.
Advice for other academic centers
For academic systems considering a similar move, Dr. Bovonratwet stressed leadership support and careful patient selection. “Every new program is going to have its ups and downs,” he said. “It’s important to start with careful patient selection and have strong support from leadership, so that when challenges arise, you know you have people who have your back.”
“If you choose patients well and indicate them well, the complication rates are very, very low,” he added. He said the conversation is worth having now, as CMS phases out its inpatient-only list and more procedures move outside the hospital “in one way or another.”
He also cautioned against letting enthusiasm outpace expectations. Patients are increasingly educated about endoscopic techniques and asking for them, he said, but reherniation rates are similar regardless of how a discectomy is performed.
“It’s important not to let patients get caught up in the marketing. We need to set expectations clearly about what these procedures can and cannot accomplish,” he said.
Large academic medical centers are only beginning this migration, he added. “There’s still a lot more work to do.”
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.
