Bobby Bhatti, MD, of Atlanta Orthopaedic Institute, discusses performing outpatient spine surgery cases in the ambulatory surgery center.
Q: Why are more surgeons performing spine cases in the outpatient setting today? What is the argument for transitioning those cases?
Dr. Bobby Bhatti: We are working on performing minimally invasive spine surgery, including single-level anterior cervical discectomy and fusion, in the outpatient setting where patients have less cost incurred and lower risk of infection. We are performing cases in ambulatory surgery centers because it's a better experience for the patients.
Q: How has technology and technique development made it possible to bring spine procedures into the outpatient setting?
BB: Surgeons in the spine field have been doing lateral procedures for 20 to 30 years, but the development of new retractor systems for introducing implants has come a long way. That's what has really allowed us to bring these procedures into the outpatient setting. In addition, we have less blood loss because the decompressions are done indirectly. Patients are up and moving faster, so they have better recoveries.
Q: What advantages are there for surgeons and patients to performing the spinal cases as outpatient procedures?
BB: As I mentioned before, less blood loss in addition to quicker operating room times. Patients can then go home and relax in their own environment, which means there is a lower risk of infection.
There are also advantages for the surgeons. Our ASC helped develop our practice, and performing cases there is more efficient for everyone. I do as many cases as possible there because of the lower risk of infection and patients don't have a huge need for narcotics afterward. It's more of a boutique experience for them and they don't have to sit in the hospital for a week recovering.
Q: What is the economic impact of being able to perform spinal surgeries in the outpatient setting?
BB: I think this is important because with the rising of the current climate in medicine and insurance, a lot of procedures will switch to outpatient because the insurance companies and patients don't want to pay for huge long stays in the hospital. It's cheaper to have it done in the outpatient setting because you don't have huge hospital fees. There are lower costs for the implant companies and the surgeon, so it's better for the entire economic environment.
Q: Medicare doesn't currently reimburse for outpatient spine surgeries in ASCs. Are commercial payers any better?
BB: Actually, yes. A lot of times — especially for cervical disc replacement — the commercial insurers aren't approving surgeries for inpatient stays, but if you put them as outpatient procedures a lot of primary insurers are approving it. For us, that makes a big difference because if we are able to do it safely in the ASC, and make sure patients are able to go home safely, a lot of surgeons are going to start performing these outpatient procedures.
Q: Where do you see the biggest opportunity for outpatient spine surgery to grow and develop in the future?
BB: A lot of opportunity, at least in the beginning, will be in the single-level fusions, disc replacement and microdiscectomies. These are the patients I currently do in the outpatient setting and then send them home. For the more complicated and multilevel fusions, we need inpatient stays. But outpatient surgery is where the future is at for procedures that can be performed there.
Q: What is the best piece of advice you have for spine surgeons just beginning to consider performing cases in the outpatient setting?
BB: You have to do what you feel comfortable doing. To start with, keep the patients overnight for one night in the hospital and see how they do. You also need to preemptively educate the patient about whether they are staying the night or going home. Have an educator in your office to speak with them. You are only as good as what you give patients on paper, so give them information about what could go wrong or right, and what issues to expect.
Have someone from your office call them that night and again the next morning to make sure they are okay. Make sure you are available so they have a good experience. If you are doing a good job and people are leaving the hospital quicker and your comorbidities are less, you will have better outcomes and become a more successful surgeon.