Seven spine surgeons discuss how the COVID-19 pandemic will affect the trend of spine surgeries moving away from hospitals toward outpatient settings.
Ask Spine Surgeons is a weekly series of questions posed to spine surgeons around the country about clinical, business and policy issues affecting spine care. We invite all spine surgeon and specialist responses.
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Note: The following responses were lightly edited for style and clarity.
Question: Will the COVID-19 pandemic accelerate the shift of orthopedic procedures from hospitals to outpatient settings? How do you see this trend developing?
James Guille, MD. Premier Orthopaedics (Pottstown, Pa.): Our new world with COVID-19 will accelerate the transition of many spinal procedures to outpatient facilities. Data have shown that there are lower infection rates and decreased costs. Theoretically, there is a decreased exposure to traffic and pathogens, compared with hospitals. Additionally, utilization of surgicenters will decrease backlogs at hospitals, freeing up resources to take care of medically complex patients requiring inpatient care. Procedures such as microdiscectomy, anterior cervical discectomy and fusion and kyphoplasty are already done on an outpatient basis at many hospitals. These patients would be the best candidates for surgicenters. Ideally, facilities with capability of overnight stay offer the option of extended observation in select patients.
Richard Kube, MD. Prairie Spine (Peoria, Ill.): I think the trend of moving to more outpatient settings makes sense. Certainly, there is greater ability to control traffic and other items related to infection. There are not any emergency patients showing up with illnesses that cannot be controlled. These aspects all benefit the young healthy patient who can safely have a procedure in an outpatient setting. One force against this happening will be consolidation that will occur as a result of financial strains created by prolonged elective case shutdown. That said, those prepared to accept patients into their outpatient facilities and add value create a proposition that is hard to ignore.
Vladimir Sinkov, MD. Sinkov Spine Center (Las Vegas): There is definitely a desire to minimize exposure to a hospital setting among healthy patients needing elective procedures. It is driven by concern for infection, need for more hospital resources to fight the pandemic, as well as intermittent and unpredictable "holds" on elective procedures in hospitals. I am confident that this situation will accelerate the shift of spine procedures to an ASC. Performing a surgery in an outpatient setting also leads to lower costs and higher patient satisfaction while maintaining the same level of safety and good patient outcomes.
However, there are some limitations to this trend. Just like other businesses, ASCs are struggling to keep up with higher demand and lower supply of personal protective equipment and other resources, which can limit their ability to increase procedure volumes. Moving higher acuity cases — like lumbar fusions — to an outpatient facility will require substantial capital investment in equipment and time to train the staff.
Brian Gantwerker, MD. Craniospinal Center of Los Angeles: It is very hard to tell. It all depends on what the payers do. I can see a shift going back to hospitals as they will try to aggressively price themselves back into the market. The song is not over for surgery centers, but I would be cautious about a race to the bottom price-wise. If done correctly, you can demonstrate great outcomes that deserve a premium on reimbursement from the carriers.
Issada Thongtrangan, MD. Microspine (Phoenix): There was a movement of elective spine surgery performing in the ASC in the past several years prior to the COVID-19 pandemic due to the advanced technology in minimally invasive techniques and the nature of ASCs. Scientific data showed comparable if not superior outcomes in elective spine surgeries in ASCs. Another important aspect of having surgery in an ASC is that the surgeon is in control of almost everything, which is great for the patients. Moving forward post-pandemic, we and the ASC have to respect the COVID-19 scientific data. We have to follow the strict guidelines and be compliant with wearing masks, social distancing, and sanitizing common areas to make sure everyone is safe. Testing patients and staff are also mandatory in some ASCs. In addition, each ASC has to know their PPE status so we are not running into the problem. Unfortunately, some major reconstruction still has to be done in the hospital.
Srdjan Mirkovic, MD. Northshore Orthopaedic & Spine Center (Skokie, Ill.): It is unlikely there will be a significant impact on outpatient procedures due to COVID-19, although it is likely there will be continued interest in outpatient care involving less invasive surgical procedures. The best candidates for outpatient surgery will remain a younger patient requiring a limited lumbar or cervical disc procedure. Most spine surgeries are best suited for inpatient care. There is no data to support that inpatient procedures increase chances of contracting the coronavirus. Furthermore, there are advantages to a spine specialty hospital where patients do not incur the risk of greater exposure such as in a general hospital. At NorthShore Orthopaedic & Spine Center, strict testing and surgical protocols are in place and no COVID-19 patients are admitted for treatment, making it an even safer hospital environment for postop care.
John Liu, MD. USC Spine Center (Los Angeles): The trend to outpatient ambulatory centers began prior to COVID-19. I think we're all going to reevaluate what cases we can do on an outpatient basis as we take the growing demand from patients for this type of care into consideration.