Dr. Michael Smith: COVID-19 can sharpen drive to move spine surgery from hospitals to ASCs


The widespread postponement of nonemergent procedures is expected to take a significant chunk out of hospital revenue in the first and second quarters, with ASCs also feeling the pinch. 

Spine and orthopedic surgeons, as well as device companies, are preparing for an imminent ramp-up period to catch up on the increasing backlog of surgical cases caused by the coronavirus pandemic.

However, many healthcare opportunities are coming out of the crisis, such as the expansion of telemedicine and rethinking the settings for spine and orthopedic surgical care.

Michael Smith, MD, of Philadelphia-based Rothman Orthopaedic Institute, performs spine surgery at the practice's New York City facilities, including Lenox Hill Hospital and Lenox Health Greenwich Village Ambulatory Surgery Center.

Here, Dr. Smith spoke to Becker's Spine Review about the rapid development of telemedicine in spine and why it makes sense to move surgical care away from hospitals toward the ASC setting.

Note: Dr. Smith's comments were lightly edited for style and clarity.

"COVID-19 has been a huge stressor on the general population and the medical community in particular. We in the spine community need to use our collective intelligence and ingenuity to move through the crisis and take advantage of a unique time of flux to improve our work environments going forward.

"The most obvious change for many of us, especially those of us at Rothman Orthopaedics New York, has been the rapid ramp-up of telemedicine capabilities and usage. This was certainly a marginal part of spine practice pre-coronavirus, but many of us are seeing its current and future value, learning under duress. In my experience, the video component makes the interaction significantly more useful than telephone alone. The physical exam is of course limited, but many other elements of the patient's condition can be determined.

"The main inherent limitation for telemedicine in spine will be new patient visits with potential for surgical decision-making. Making a recommendation for surgery without having laid hands on the patient will be, and should be, an uncomfortable idea for us as clinicians.

"Its more powerful roles may be in screening new patients and postop visits. For instance, we could develop a willingness to 'see' acute neck or back pain, ruling out red flag symptoms, sending patients for initial X-rays, physical therapy, and anti-inflammatory trials, as well as having those with persisting symptoms come in for an in-office visit two to three weeks later. This could broaden our availability and responsiveness to more patients who previously we may not have wanted to see at all.

"While some patients really need an in-office follow-up after surgery, many routine spine patients can tell us in two minutes on a video chat whether our surgery was successful. One can imagine the patient emailing a picture of his or her incision, filling out their functional status questionnaires on the online portal and getting their X-ray close to home. The postop visit becomes a 10 minute interaction with all necessary information conveniently on your computer screen, before saying a virtual hello. This would be very satisfying and convenient to patients who come from far away, as is often the case in New York City and in rural areas.

"Another major opportunity we could take from the COVID-19 crisis is sharpening our drive to move the great majority of spine surgical care out of hospitals. A variety of cultural, institutional, financial and regulatory issues make it easy for many of us to keep operating in a hospital. It is comfortable for most of us; it is how most of us trained, and most of our learned professors had no reason to bother looking outside the hallowed halls. But we see a great limitation in our hospitals now as they have been suddenly and completely taken from us by a single virus. Hospitals are not specifically built to be optimized for spinal care. 

"ASCs, especially with an overnight nursing option, and facilities that can extend care for 1-2 postoperative days should be able to accommodate a significant majority of spinal care. Minimally invasive techniques support this transition. Surgeon ownership and management of these centers can build efficiencies for the physicians and the patients that are structurally impossible in a large and complicated hospital. For those of us who have really only known life in academic medical centers, where the surgeon's control of anything other than the actual cutting is very limited, could find this a brave and bright new world."

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