Surgeon Analysis: Outpatient Lumbar Discectomy has Excellent Results, is Safe and Low Cost at ASCs

Laura Dyrda -  
After completing data analysis as part of an ongoing assessment on patients receiving an outpatient lumbar discectomy at Centennial Lakes Surgery Center, an affiliate of Surgical Care Affiliates, in Edina, Minn., Jeffrey Dick, MD, has concluded that the procedure has excellent outcomes, is safe and can be done with low costs in ASCs. "The outpatient lumbar discectomy is certainly a very reasonable procedure to do in an outpatient surgery center," says Dr. Dick. "The procedure can be done at a low expense and have excellent outcomes that are equal to surgeries done in a hospital with high-tech equipment with far greater cost."

Result significance
Many physicians do not perform outpatient lumbar discectomies in ASCs because the ASC does not have the same resources as hospitals, such as expensive microscopes or “minimally invasive” tube systems, and the reimbursement to the ASC is substantially less than the reimbursement to a hospital, says Dr. Dick. However, he says performing the procedure in an ASC results in excellent outcomes, is safe and has the potential to cut healthcare costs in the future.

"With this diagnosis and procedure, an inexpensive low-tech procedure in an outpatient surgery center is as effective as those performed in a hospital," says Dr. Dick.

In order to cut costs, Dr. Dick says the procedure can be performed safely and effectively without a microscope or a “minimally invasive” tube system.  

“In slender patients my incision is as small as or smaller than that required for the tube systems.” Dr. Dick uses magnifying loupes and a headlight and feels that this provides excellent visualization. Additionally, he gives his patients the option of general or local anesthesia with intravenous sedation.

"When we compared the outcomes, there was no significant difference between patients who chose local or general anesthesia," says Dr. Dick. "You can have excellent outcomes with this procedure without spending lots of money."

Since this procedure can be performed at a low cost in the ASC, Dr. Dick believes payers will eventually encourage their patients to have the procedure in an ASC instead of a hospital. Medicare and insurance companies reimburse surgery centers at a lower rate than hospitals, which means having the procedure at an ASC is more cost-effective.

Data analysis
In order to assess the outpatient lumbar discectomy's effectiveness, Dr. Dick administered the Oswestry Disability Index (ODI) and visual analog scales (VAS) for back and leg pain to his patients pre-operatively and at one and three months postoperatively.

The ODI consists of 10 questions about a patient’s pain and functional capabilities in everyday activities. Typical questions ask the patient to score their pain intensity and their abilities in standing, sitting, walking, lifting, personal care, traveling, sleeping and even sexual activity.

"The ODI is a scoring system that's been validated and is very well accepted in the spine community as a good way to assess a patient’s functional level," says Dr. Dick.  A typical person without any handicap will score below 15 out of one hundred. In the patients that Dr. Dick studied the preoperative scores averaged 50.  Three months after surgery the average score was 12.  

The VAS is administered by presenting the patient with a ten-centimeter scale, like a thermometer, where they place a mark between 0 (no pain) and 10 (the worst pain imaginable). The patients were given on scale for back pain and one for leg pain.  

“Patients suffering from a lumbar disc herniation typically present with mostly leg pain and this pain is often very handicapping.” In Dr. Dick’s patients the average preoperative leg pain was seven with a range from two to ten. Three months after surgery the average leg pain was one. The pre and post-operative differences were statistically significant for both the ODI and VAS.

In addition, Dr. Dick compared groups of patients with different life circumstances, such as smokers versus non-smokers, patients with a BMI of 30 versus those with a BMI of less than 30, whether the injury was work-related and the different genders. His analysis showed no significant difference in the recovery between these patients, which was surprising to him.

"In most studies of spine surgery and orthopedic surgery, those whose condition is caused by a work injury often don't do as well. smokers and obese patients also don't do as well," says Dr. Dick. His statistical analysis showed these patients doing as well as their counterparts three months after surgery. "However, I think there would probably be a difference if there were a longer follow-up period."

Future impact

Dr. Dick's current data analysis supports the effectiveness and safety of performing outpatient lumbar discectomy in an ASC at a lower cost to the payor, which means a lower cost of healthcare.  Dr. Dick is also doing one level, anterior cervical fusions and disc replacements in the outpatient setting, although the numbers are not as large as his discectomy group, he is seeing similar good outcomes.

"There's probably going to be a shift to the surgery centers from the hospitals for some of the simpler spine procedures. That has been the trend in general orthopedics over the last 20 years," says Dr. Dick. "Many procedures have shifted from the inpatient to the outpatient setting. This trend has decreased the cost of care without compromising the quality of it."

Learn more about Centennial Lakes Surgery Center.

Learn more about Surgical Care Affiliates.

Read other coverage on spine surgery advancement:

- 5 Best Practicies to Improve Spine Efficiency in ASCs

- Why Patient Selection Matters to Spine-Focused ASCs: Q&A With Dr. Thomas Forget

- A Big-Picture Vision for Spine Care: Q&A With Dr. John Caruso

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