'The death knell for inpatient spine' & other forecasts for the setting in 5 years


The spine surgical landscape is expected to change dramatically as outpatient migration accelerates and CMSeliminates its inpatient-only list by 2024. Five spine surgeons discuss how inpatient spine surgery will look like five years from now.

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.

Next week's question: What technology do you see as the next true game-changer in spine surgery?

Please send responses to Alan Condon at acondon@beckershealthcare.com by 5 p.m. CDT Wednesday, June 9.

Note: The following responses were lightly edited for style and clarity.

Question: What will inpatient spine surgery look like five years from now?

Michael Gordon, MD. Hoag Orthopedic Institute (Orange County, Calif.): In the next five years, spine surgery will look much different in the hospital setting. Most one- and two-level cervical surgery, and most one-level lumbar surgery will be outpatient. Inpatient surgery will be predominantly multilevel fusion and decompression surgeries on an aging population with multiple comorbidities. Complex reconstructions and tumor surgery will be the most commonly performed inpatient procedures. 

I expect  that improvements in imaging technologies and minimally invasive techniques will push current procedures to the outpatient setting. This will be due to improvements in technology's ease of use, reliability and cost, particularly in current robotic platforms. Wearable goggle imaging devices, I hope, will mature to the level of current automobile moving map displays to improve surgeon 3D awareness. As always, the cost of new developments must be met with improvements in patient cost of care and outcomes measures.

Brian Gantwerker, MD. Craniospinal Center of Los Angeles: Inpatient spine surgery will mostly be relegated to emergent cases, such as infections, pathological fractures and neoplasms as well as large complex deformity cases. By moving all of the inpatient-only codes outpatient, CMS has effectively sounded the death knell for inpatient spine. I am fairly certain this was unintentional, but as with most things in medicine, forethought ends up as hindsight. Surgery centers will contain the bulk of surgical cases, both in terms of minimally invasive surgery as well as two-level lateral and most multilevel arthroplasty cases. I sincerely hope surgeons will continue to use good judgment as to who should and should not have surgery on the inpatient side.  

There will be more surgeries done as overnight stays (outpatient) in the hospital, but I would find it hard to not see surgery centers applying for and getting extended stay (under 36 hours) exemptions for cases. While this may sound attractive to CMS and Congress in terms of healthcare savings, it could be the admission or urgent transfer of cases that are a 'bridge too far' to the hospital setting that will undoubtedly wipe out any long-term savings.  

Noam Stadlan, MD. NorthShore Neurological Institute and NorthShore Spine Center (Evanston and Skokie, Ill.):The number of inpatient surgery patients is decreasing due to an increased emphasis on outpatient surgery and shortening length of stay with enhanced recovery after surgery protocols. The usual reasons for inpatient stays after spine surgery involve the following concerns: neurological status, functional status, medical and pain. Over time, surgical pain will be reduced and treatment will be optimized, so inpatient stays for pain will go down significantly. Similarly, but perhaps not to the same extent, better and more active medical clearance and prehabilitation will result in less inpatient stays for medical issues. Therefore, inpatient stays after spine surgery will be increasingly for those who have poor functional status and/or require monitoring for neurological status. 

Alok Sharan, MD. NJ Spine and Wellness (East Brunswick, N.J.): As more spine surgery evolves towards the outpatient space, it is clear that we will see fewer surgeries being performed in the typical inpatient setting. Complex spine deformities, spinal oncology cases and traumatic injuries will be commonly performed in the inpatient setting. Initially, as surgeons come out of training, they will be more inclined to do their cases in the hospital.  As the systems to optimize a patient properly evolve, these surgeons will migrate their cases towards the outpatient setting.

Nitin Khanna, MD. Spine Surgeon and Founder of Spine Care Specialists (Munster, Ind.): ​Inpatient surgery will slowly be reserved for higher-acuity cases. There is still a big role for inpatient spine surgery for adult and pediatric deformity, complex medical comorbidities, as well as tumor, trauma and infections. It is not sustainable for every outpatient spine surgical-eligible patient to have their surgery in a hospital. You would drive a car and not take a 747 airplane by yourself to work every day. I have published and presented on outpatient surgery at the International Journal of Spine Surgery and the Society for Minimally Invasive Spine Surgery. Safety, cost effectiveness and patient satisfaction have all been proven in the outpatient setting by many of my spine colleagues. The future looks bright for people suffering with spinal pain that now have so many minimally invasive outpatient options that can reliably relieve their suffering.

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