Transitioning from Hospital-based to Office-Based Practice.

The decision to change your career path from a hospital-based practice, whether it's from being a hospital employee or a member of a private practice, can be an emotionally draining choice that is complex and overwhelming to say the least. There are many factors to consider before making this switch, but most importantly, one must realize it may be the hardest but most rewarding work in your career. While the physical, emotional and financial stresses placed on you while developing a practice can be rather demanding, on the flip side, if done correctly and the practice thrives, it can be a change that will bring you great pride and satisfaction, as well as personal reward and freedom.

A Case of Hospitalization After Pre-operative Interscalene Nerve Block in an Ambulatory Surgery Center.

Interscalene nerve block (ISB) is an effective and low-risk local anesthetic (LA) procedure that is commonly employed for shoulder surgery. While phrenic nerve involvement occurs to some degree in every ISB procedure, the incidence of hypoxemia and other clinical signs of diaphragmatic disruption is much lower. This is a case of a 36-year-old female with no underlying respiratory disease who developed hypoxemia requiring a night of observation following an ISB for a rotator cuff repair procedure in an ambulatory surgical center. Her hypoxemia was easily treated with supplemental oxygen and she made a full recovery by the next day. The use of ultrasound guidance, reduced LA volume, less potent medication, sterile fluid for optimal visualization, and extrafascial administration should be considered for all patients receiving an ISB to prevent respiratory complications.

Surgeon Perceptions of Performing Transforaminal Lumbar Interbody Fusion in an Ambulatory Surgical Center vs Hospital Setting in the Elderly Population: Results of a Surgeon Survey.

BACKGROUND: There is an increasing acceptance of conducting minimally invasive transforaminal lumbar interbody fusion (TLIF) in ambulatory surgical centers (ASCs). The Centers for Medicare and Medicaid Services (CMS) introduced the Hospitals Without Walls (HWW) program in March 2020. This program granted hospitals regulatory flexibility to offer services and procedures in nontraditional locations, including ASCs. However, implementation hurdles persist. METHODS: A survey was sent to 235 surgeons regarding the use of ASCs for performing TLIF surgeries on elderly patients. Multiple-choice questions covering various aspects of TLIF practice preferences, including surgical indications, decision factors for choosing ASCs over hospitals, implementation hurdles, reimbursement concerns, staffing issues, and the impact of CMS rules and regulations on TLIF in ASCs, particularly concerning physician ownership and self-referral conflicts governed by the Stark law, were asked. RESULTS: The survey completion rate was 25.8% (Figure 1). The most common surgical indications for TLIF in ASCs were spondylolisthesis (80%), spinal stenosis (62.5%), and low back pain (47.5%). Most surgeons (78%) believed TLIF could be safely performed in ASCs. Streamlined workflow, lower infection rates, and cost-effectiveness were advantages listed by 58.5% of surgeons. Patient's medical history (75.8%), followed by ASC resources and capabilities (61%) and surgeon preference (61%), were relevant factors. Higher efficiencies at ASCs (14.6%), contractual issues (9.8%), and ownership issues (7.3%) were less relevant to surgeons. About 65.9% of surgeons reported lower reimbursement in ASCs, and 43.9% said it was an implementation hurdle. Lower direct costs were reported by 53.7% of surgeons. Other hurdles included a lack of trained staff (24.4%), inadequate staffing (22.0%), cost overruns (26.8%), high Joint Commission or the Accreditation Association for Ambulatory Health Care credentialing costs, and surgeons feeling uncomfortable performing TLIF in ASCs (22.0%). Only 17.1% listed medical problems as a reason their patient was considered unsuitable for the ASC environment. A majority (53.7%) stated that their ASCs complied with strict Stark requirements by disclosing physician ownership interests. However, 22% of surgeons reported self-referrals under the "In-Office Ancillary Services Exception" allowed by the Stark law. CONCLUSION: Our survey data show that surgeons' perceptions of current CMS rules and regulations may hinder the transition into the ASC setting because they think the reimbursement is too low and the regulatory burden is too high. ASCs have disproportionally higher initial acquisition and ongoing costs related to staff training and maintenance of the TLIF technology that CMS should consider when determining the appropriate financial remuneration for these complex procedures. CLINICAL RELEVANCE: ASC offers a viable and attractive option for their TLIF procedure with the advantage of same-day discharge and at-home recovery.

Older Age, Male Sex, and Early Start Time Lengthen the Recovery Room Stay Following Total Joint Arthroplasty in an Ambulatory Surgical Center.

Background: Total joint arthroplasty (TJA) performed in the ambulatory surgical center (ASC) has been shown to be safe and cost-effective for an expanding cohort of patients. As criteria for TJA in the ASC become less restrictive, data guiding the efficient use of ASC resources are crucial. Purpose: We sought to identify factors associated with length of stay in the recovery room after primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) performed in the ASC. Methods: We conducted a retrospective review of 411 patients who underwent primary THA or TKA at our institution's ASC between November 2020 and March 2022. We collected patient demographics, perioperative factors, success of same-day discharge (SDD), and length of time in the recovery room. Results: Of 411 patients, 100% had successful SDD. The average length of time spent in recovery was 207 minutes (SD: 73.9 minutes). Predictors of longer time in recovery were increased age, male sex, and operative start time before 9:59 am. Body mass index, preoperative opioid use, Charlson Comorbidity Index, type of surgery (THA vs TKA), urinary retention risk, and type of anesthesia (spinal vs general) were not significant predictors of length of time in the recovery room. Conclusion: In this retrospective study, factors associated with increased length of time in the recovery room included older age, male sex, and operative start time before 9:59 am. Such factors may guide surgeons in determining the optimal order of cases for each day at the ASC, but further prospective studies should seek to confirm these observations.

Success of Same-Day Discharge Total Hip and Knee Arthroplasty: Does Location Matter?

BACKGROUND: Same calendar day discharge (SCDD) following total joint arthroplasty is desirable for patients and surgeons alike. The aim of this study was to compare the success rate of SCDD in an ambulatory surgical center (ASC) versus hospital setting. METHODS: A retrospective analysis was performed on 510 patients who underwent primary hip and knee total joint arthroplasty over a 2-year period. The final cohort was divided into 2 groups based on location of surgery: ASC (N = 255) or hospital (N = 255). Groups were matched for age, sex, body mass index, American Society of Anesthesiologists score, and Charleston Comorbidity Index. Successes of SCDD, reasons for failure of SCDD, length of stay (LOS), and 90-day readmission and complication rates were recorded. RESULTS: All SCDD failures were from the hospital setting (36 [65.6%] total knee arthroplasty [TKA] and 19 [34.5%] total hip arthroplasty [THA]). There were no failures from the ASC. The main causes of failed SCDD in both THA and TKA included failed physical therapy and urinary retention. Regarding THA, the ASC group had a significantly shorter total LOS (6.8 [4.4 to 11.6] versus 12.8 [4.7 to 58.0] hours, P < .001). Similarly, TKA patients had a shorter LOS in the ASC (6.9 [4.6 to 12.9] versus 16.9 [6.1 to 57.0], P < .001). Total 90-day readmission rates were higher in the ASC group (2.75% versus 0%), where all but 1 patient underwent TKA. Similarly, complication rates were higher in the ASC group (8.2% versus 2.75%), where all but 1 patient underwent TKA. CONCLUSION: TJA performed in the ASC, compared to the hospital setting, allowed for reduced LOS and improved success of SCDD.

Modern robotics platform associated with reduced 90-day complications in hospital setting.

BACKGROUND: Early complications in total knee arthroplasty (TKA) associated with modern robotics platforms integrated with digital balancing technology have not been investigated. OBJECTIVE: The objective was to compare 90-day complication rates between a manual technique and a modern robotic-assisted ligament balancing TKA platform. METHODS: 895 primary TKA procedures from a single surgeon were retrospectively reviewed (614 manual TKA, 281 using a modern robotics platform with an integrated digitally controlled ligament balancing device). Post-operative complications within the 90-day episode of care were recorded by the Michigan Arthroplasty Registry Collaborative Quality Initiative. Differences in complication rates between techniques were further divided into inpatient hospital, outpatient hospital, and ambulatory surgery center (ASC) cohorts. RESULTS: In the pooled hospital cohort and inpatient hospital cohort, 'Return to OR' was significantly lower for the robotic assisted group (1.3% vs 5.2% and 0% vs 4.9%, respectively, p< 0.0370). Specifically, the need for manipulation under anesthesia (MUA) was reduced for the robotics group (0.0% vs 2.5%, p= 0.0352). No differences in overall complication rate or cause of complication was found between manual and robotics cases for the hospital outpatient and ASC cohorts (p⩾ 0.68). CONCLUSION: Within the hospital setting, robotic assisted ligament balancing technology was associated with reduced 90-day postoperative complications for 'Return to OR' and MUA.

Analysis of Sociodemographic Factors Affecting Ambulatory Surgical Center Discharge Patterns for Endometrial Cancer Hysterectomies.

STUDY OBJECTIVE: Investigate outcomes for patients undergoing minimally invasive hysterectomies (MIHs) performed for endometrial cancer at ambulatory surgery centers (ASCs). DESIGN: Our study aimed to explore the feasibility and discharge outcomes for MIHs for endometrial cancer in an ASC setting by using same-day discharge data. SETTING: The prevalence of MIH for endometrial cancer between 2016 and 2019 was estimated from the Nationwide Ambulatory Surgery Sample. PATIENTS: Patients who underwent MIHs for endometrial cancer at an ASC were included. INTERVENTIONS: N/A MEASUREMENTS MAIN RESULTS: Weighted estimates of prevalence and association between discharge status and sociodemographic factors were explored. Same-day discharge was defined as discharge on the day of surgery, and delayed discharge was defined as discharge after the day of surgery. An estimated 95 041 MIHs for endometrial cancer were performed at ASCs between 2016 and 2019. Notably, 91.9% (n = 87 372) resulted in same-day discharge, 1.2% (n = 1121) had delayed discharge, and 6.9% (n = 6548) had missing discharge information; 78.7% procedures (n = 68 812) were performed at public hospitals. The proportion of delayed discharges were lower in private, not-for profit ASCs (0.8%, p = .03) than public hospitals. Patients who had delayed discharges on average were older (69.7 vs 62.4 years, p <.001), more likely to have comorbid conditions including diabetes (adjusted odds ratio [aOR] 1.48, 95% confidence interval [CI] 1.25-1.75) and overweight or obese body mass indices (aOR 1.18, 95% CI 1.01-1.39), and more likely to have public insurance (aOR 1.78, 95% CI 1.40-2.25). CONCLUSION: MIHs for endometrial cancer are feasible in an ASC. Optimal candidates for receipt of MIHs for endometrial cancer at an ASC are patients who are younger and have less comorbidities, lower body mass index, and private insurance.

Peripheral Arterial Disease Treatment in the Non-Hospital Setting.

Treatment of peripheral artery disease (PAD) has undergone a progressive shift toward less invasive, endovascular options within the last three decades. For PAD patients, the benefits of this shift are numerous and include less periprocedural pain, decreased blood loss, shorter recovery times, and fewer missed workdays. Commonly, patient-reported outcomes are very positive with this "endovascular first" strategy and the number of open surgical procedures for various stages of PAD has declined steadily over the last 20 years. Coincident with this trend is the move toward "ambulatory" lower extremity arterial intervention (LEAI) in the hospital outpatient "same-day" department. The next logical extension was then performing LEAI in a true physician office-based lab (OBL), ambulatory surgical center (ASC), or "non-hospital setting." This article examines these trends and the concept that the OBL/ASC provides a safe, alternative site of service for PAD patients requiring LEAI.

Outcomes of elective peripheral endovascular interventions for peripheral arterial disease performed in hospital outpatient departments, ambulatory surgical centers and office-based labs.

BACKGROUND: A recent shift in the location where peripheral endovascular interventions (PVI) are performed has occurred, from traditional settings such as hospital outpatient departments (HOPD), to ambulatory surgical centers (ASC) and outpatient-based laboratories (OBL). Different settings may influence the safety and efficacy of the PVI, as well as how it is done. This study aims to compare the postprocedural outcomes and intraprocedural details between the three settings. METHODS: The Vascular Quality Initiative database was queried for all elective infrainguinal PVIs for occlusive peripheral arterial disease between January 2016 and December 2021. The primary outcomes were rates of postprocedural hospital admissions, postprocedural medical complications, and access site complications. Secondary outcomes included technical success and intraprocedural details, such as types and number of devices used, amount of contrast, and fluoroscopy time. The χ2 test, analysis of variance, and multivariate logistic regression were used to analyze the outcomes. RESULTS: A total of 66,101 PVI cases (HOPD, 57,062 [83.33%]; ASC, 4591 [6.95%]; OBL, 4448 [6.73%]) were included in the study. There were 445 cases requiring hospital admission (HOPD, 398 [0.70%]; ASC, 26 [0.57%]; OBL, 21 [0.47%]; P = .126). There were no significant differences in cardiac, pulmonary, or renal complications. Access site complications occurred in less than 1.7% of all cases and were significantly higher in OBLs when compared with ASCs (adjusted odds ratio [aOR], 3.70; 95% confidence interval [CI], 1.70-8.03; P = .001) and significantly lower in ASCs in comparison to HOPDs (aOR, 0.27; 95% CI, 0.18-0.41; P < .001). Technical success occurred in at least 92% of all cases, regardless of setting. There was a 16-fold increase in the use of atherectomy devices in an OBL vs HOPD setting (aOR, 16.79; 95% CI, 11.77-23.95; P < .001) and a five-fold increase in the use of atherectomy devices in an ASC vs HOPD setting (aOR, 5.37; 95% CI, 2.47-11.65; P < .001). There was a five-fold decrease in the use of special balloons in an OBL vs HOPD setting (aOR, 0.20; 95% CI, 0.10-0.39; P < .001) and a four-fold decrease when comparing ASCs with HOPDs (aOR, 0.25; 95% CI, 0.12-0.51; P < .001). CONCLUSIONS: Elective PVIs performed in any outpatient setting proved to be safe and technically successful. However, there are significant differences in the way PVIs are performed in each setting, such as the greater use of atherectomy devices in OBLs and greater use of special balloons in HOPDs. Long-term studies are needed to evaluate the durability and reintervention outcomes and understand factors associated with practice pattern variability across these different settings.

Clinical and economic impact of blue light cystoscopy in the management of NMIBC at US ambulatory surgical centers: what is the site-of-service disparity?

INTRODUCTION AND OBJECTIVE: Management of non-muscle-invasive bladder cancer (NMIBC) significantly impacts healthcare resource utilization due to requirements for ongoing surveillance. White light cystoscopy (WLC) represents the traditional approach to NMIBC disease surveillance, though physicians utilizing WLC alone may fail to detect all cancerous lesions. The approval of blue light cystoscopy (BLC) as an adjunct to WLC enhances the urologist's ability to more readily detect cancerous tissue. A more complete resection will reduce recurrences and could result in reduced costs for the US healthcare system. This analysis quantifies the clinical and economic impact of the incorporation of BLC in the management of NMIBC in ambulatory surgical centers (ASCs) considering current Center for Medicare Services (CMS) patient-physician coverage and reimbursement. METHODS AND MATERIALS: A budget impact model was developed to assess projected ASC costs for a cohort of 50 newly diagnosed bladder cancer patients over a 2-year follow-up comparing WLC alone vs. WLC + BLC. Treatment and surveillance intervals were based on AUA/SUO clinical guidelines. Clinical and cost metrics for staging and biopsy rates were assessed, with cost inputs based on Medicare reimbursement rates. RESULTS: Use of WLC + BLC for NMIBC surveillance resulted in the identification of 5 additional NMIBC recurrences compared to WLC alone. There was an associated increased cost of performing BLC in an ASC setting, with a net increase in the total cost of care for NMIBC of $110 per cystoscopy over a 2-year period. If recurrences missed using WLC alone were to progress prior to detection, the model projects an increase in treatment costs borne by Medicare of $9,097 to $34,538 due to more intensive treatments required for the increased risk of recurrence. CONCLUSIONS: Modeled results suggests that the Medicare program will incur increased costs, due to the gap between added costs per cystoscopy due to BLC. The current discrepancy in reimbursement disincentivizes community-based ASCs from adopting BLC, resulting in suboptimal patient care while increasing downstream treatment costs to Medicare, necessitated when missed disease progresses to higher stage/grade disease. The findings have important clinical implications for the optimal management of NMIBC and should inform healthcare policies that promote cost-effectiveness and enhanced patient outcomes.

Evaluation of Regional Geospatial Clusters in Inguinal Hernia Repair.

Introduction There is significant variation in how inguinal hernia repairs are conducted across the United States (US). This study seeks to utilize national public data on inguinal hernia repair to determine regional differences in the use of ambulatory surgical centers (ASC) and in the choice of laparoscopic or open technique. Methods Medicare provider billing and enrollee demographic data were merged with US census and economic data to create a county-level database for the years 2014-2019. Location, technique, and total count of all inguinal hernia repair billing were recorded for 1286 counties. Moran's I cluster analysis for inguinal hernia repairs, percent laparoscopic technique, and percent ACS were conducted. Subsequent hotspot and coldspot clusters identified in geospatial analysis were compared using ANOVA across 50 socioeconomic variables with a significance threshold of 0.001.  Results  There were 292,870 inguinal hernia repairs, of which 39.8% were conducted laparoscopically and 21.3% of which were in an ACS. Inguinal hernia repair coldspots were in the Mid-Atlantic and Northern Midwest, while hotspots were in Nebraska, Kansas, and Maryland (3.85 and 36.53 repairs per 1000 beneficiaries, respectively). Compared to coldspots, hotspot areas of repair were less obese, had less tobacco use, older, and less insured; there were no differences in gender, white population, or county urbanization (p<0.001). Laparoscopic technique coldspots were in the Mid-Atlantic, Michigan, and Great Plains, while hotspots were in the Rocky Mountains and contiguous states from Florida to Wisconsin (6.14% and 75.39%, respectively). ACS coldspots were diffusely scattered between Oklahoma and New Hampshire, while hotspots were in California, Colorado, Maryland, Tennessee, and Indiana (0.51% and 48.71%, respectively). Conclusions Inguinal hernia repair, the surgical setting, and the choice of technique demonstrated interesting geospatial trends in our population of interest that have not been previously characterized.

Readability Analysis of Patient-Accessible Information Regarding Ambulatory Surgical Center Procedures.

BACKGROUND: As spine surgery in the ambulatory setting becomes more frequent, patients should comprehend the difference from traditional hospital-based, outpatient settings. Limited research exists on the readability of online articles surrounding spine surgery in the ambulatory surgery center (ASC). In this study, we intend to evaluate the readability of online articles pertaining to spine surgery in the outpatient and ambulatory surgical settings. METHODS: Three search engines were queried, and the first 100 articles pertaining to each outpatient spine surgery search term were collected. Advertisements, videos, and peer-reviewed scientific articles were excluded. Articles were categorized by publishing source as follows: hospital or institution, general medical Websites, private practice, or surgery center. Flesch-Kincaid (FK) grade level, Flesch Reading Ease (FRE) score, word count, sentences per paragraph, words per sentence, and characters per word were evaluated for each article. Student's t tests compared readability metrics between groups based on setting and procedure region. RESULTS: A total of 342 articles was analyzed; 279 articles were outpatient hospital related, and 63 ASC related. Flesch-Kincaid grade levels or FRE scores were not significantly different between outpatient hospital and ambulatory center. Comparison of ASC to outpatient articles from a hospital or institution source significantly differed in FRE score (40.7 versus 32.4) and FK grade level (12.3 versus 13.9; all P < .05). Articles addressing procedure type were significantly different in FRE score (36.2 versus 30.0) and FK grade level (13.0 ± 2.1 versus 14.3 ± 1.8). CONCLUSIONS: Hospital, private practice, and medical journalists should be aware of significant differences in readability of patient-accessible ASC articles. These articles may be more difficult to read than outpatient hospital articles, and production of more reading-level-appropriate online literature is required. LEVEL OF EVIDENCE: 3 CLINICAL RELEVANCE: There is a significant difference in the readability of patient-accessible ASC articles.

Do all outpatient spine surgeries cost the same? Comparison of economic outcomes data from a state-level database for outpatient lumbar decompression performed in an ambulatory surgery center or hospital outpatient setting.

OBJECTIVE: Spinal procedures are increasingly conducted as outpatient procedures, with a growing proportion conducted in ambulatory surgery centers (ASCs). To date, studies reporting outcomes and cost analyses for outpatient spinal procedures in the US have not distinguished the various outpatient settings from each other. In this study, the authors used a state-level administrative database to compare rates of overnight stays and nonroutine discharges as well as index admission charges and cumulative 7-, 30-, and 90-day charges for patients undergoing outpatient lumbar decompression in freestanding ASCs and hospital outpatient (HO) settings. METHODS: For this project, the authors used the Florida State Ambulatory Surgery Database (SASD), offered by the Healthcare Cost and Utilization Project (HCUP), for the years 2013 and 2014. Patients undergoing outpatient lumbar decompression for degenerative diseases were identified using CPT (Current Procedural Terminology) and ICD-9 codes. Outcomes of interest included rates of overnight stays, rate of nonroutine discharges, index admission charges, and subsequent admission cumulative charges at 7, 30, and 90 days. Multivariable analysis was performed to assess the impact of outpatient type on index admission charges. Marginal effect analysis was employed to study the difference in predicted dollar margins between ASCs and HOs for each insurance type. RESULTS: A total of 25,486 patients were identified; of these, 7067 patients (27.7%) underwent lumbar decompression in a freestanding ASC and 18,419 (72.3%) in an HO. No patient in the ASC group required an overnight stay compared to 9.2% (n = 1691) in the HO group (p < 0.001). No clinically significant difference in the rate of nonroutine discharge was observed between the two groups. The mean index admission charge for the ASC group was found to be significantly higher than that for the HO group ($35,017.28 ± $14,335.60 vs $33,881.50 ± $15,023.70; p < 0.001). Patients in ASCs were also found to have higher mean 7-day (p < 0.001), 30-day (p < 0.001), and 90-day (p = 0.001) readmission charges. ASC procedures were associated with increased charges compared to HO procedures for patients on Medicare or Medicaid (mean index admission charge increase $4049.27, 95% CI $2577.87-$5520.67, p < 0.001) and for patients on private insurance ($4775.72, 95% CI $4171.06-$5380.38, p < 0.001). For patients on self-pay or no charge, a lumbar decompression procedure at an ASC was associated with a decrease in index admission charge of -$10,995.38 (95% CI -$12124.76 to -$9866.01, p < 0.001) compared to a lumbar decompression procedure at an HO. CONCLUSIONS: These "real-world" results from an all-payer statewide database indicate that for outpatient spine surgery, ASCs may be associated with higher index admission and subsequent 7-, 30-, and 90-day charges. Given that ASCs are touted to have lower overall costs for patients and better profit margins for physicians, these analyses warrant further investigation into whether this cost benefit is applicable to outpatient spine procedures.

Impact of the COVID-19 Pandemic on Utilization of EGD and Colonoscopy in the United States: An Analysis of the GIQuIC Registry.

BACKGROUND AND AIMS: The coronavirus disease 2019 (COVID-19) pandemic has limited the ability to perform endoscopy. The aim of this study was to quantify the impact of the pandemic on endoscopy volumes and indications in the United States. METHODS: We performed a retrospective analysis of data from the GI Quality Improvement Consortium (GIQuIC) registry. We compared volumes of colonoscopy and esophagogastroduodenoscopy (EGD) during the pandemic (March-September 2020) to before the pandemic (January 2019-February 2020). The primary outcome was change in monthly volumes. Secondary outcomes included changes in the distribution of procedure indications and in procedure volume by region of United States, patient characteristics, trainee involvement, and practice setting, as well as colorectal cancer diagnoses. RESULTS: Among 451 sites with 3514 endoscopists, the average monthly volume of colonoscopies and EGDs dropped by 38.5% and 33.4%, respectively. There was regional variation, with the greatest and least decline in procedures in the Northeast and South, respectively. There was a modest shift in procedure indications from prevention to diagnostic, an initial increase in performance in the hospital setting, and a decrease in procedures with trainees. The decline in volume of colonoscopy and EGD during the first 7 months of the pandemic was equivalent to approximately 2.7 and 2.4 months of prepandemic productivity, respectively. Thirty percent fewer colorectal cancers were diagnosed compared to expected. CONCLUSION: These data on actual endoscopy utilization nationally during the pandemic can help in anticipating impact of delays in care on outcomes and planning for the recovery phase.

Single-Stage Bilateral Total Hip Arthroplasty in an Ambulatory Surgical Center: A Report of Three Cases.

In recent years, there has been increased interest in transitioning total joint arthroplasty procedures from inpatient settings to ambulatory surgical centers to decrease costs and eliminate the need for hospital stays. In addition, simultaneous bilateral total hip arthroplasty (THA) has been found to be favorable in certain patient populations when compared with staged bilateral THA. In this study, we report the results of a series of three patients who underwent single-stage bilateral THA in a free-standing ambulatory surgical center with excellent short-term outcomes and no 90-day complications.

Implementation of Outpatient Minimally Invasive Lumbar Decompression at an Academic Medical Center without Ambulatory Surgery Centers: A Cost Analysis and Systematic Review.

BACKGROUND: Lumbar decompressions are increasingly performed at ambulatory surgery centers (ASCs). We sought to compare costs of open and minimally invasive (MIS) lumbar decompressions performed at a university without dedicated ASCs. METHODS: Lumbar decompressions performed at a tertiary academic hospital or satellite university hospital dedicated to outpatient surgery were retrospectively reviewed. Care pathways were same-day, overnight observation, or inpatient admission. Patient demographics, American Society of Anesthesiologists classification, Charlson Comorbidity Index, surgical characteristics, 30-day readmission, and costs were collected. A systematic review of lumbar decompression cost literature was performed. RESULTS: A total of 354 patients, mean age 55 years with 128 women (36.2%), were reviewed. There was no significant difference in age, gender, body mass index, American Society of Anesthesiologists classification, or Charlson Comorbidity Index between patients treated with open and minimally invasive surgery. Open decompression was associated with higher total cost ($21,280 vs. $14,407; P < 0.001); however, this was driven by care pathway and length of stay. When stratifying by care pathway, there was no difference in total cost between open versus minimally invasive surgery among same-day ($10,609 vs. $11,074; P = 0.556), overnight observation ($14,097 vs. $13,992; P = 0.918), or inpatient admissions ($24,507 vs. $27,929; P = 0.311). CONCLUSIONS: When accounting for care pathway, the cost of open and MIS decompression were no different. Transition from a tertiary academic hospital to a university hospital specializing in outpatient surgery was not associated with lower costs. Academic departments may consider transitioning lumbar decompressions to a dedicated ASC to maximize cost savings; however, additional studies are needed.

Complication rates following hip arthroscopy in the ambulatory surgical center.

There has been an increase in the number of hip arthroscopy procedures performed in the outpatient setting. The purpose of this study was to query a national database to compare post-operative adverse events between hip arthroscopy procedures performed in hospital based outpatient departments (HOPD) versus ASC's. The Humana Claims Database was queried for all patients undergoing hip arthroscopy performed between 2007 and 2016, using the PearlDiver supercomputer. The study population was divided into two cohorts based on the surgical setting, ASC or HOPD. Complications of interest occurring within 90 days after surgery included Center for Medicare and Medicaid Services (CMS)-reportable complications, readmission, and return to the operating room. Visits to the emergency department after 7 days of surgery was also studied. Univariate comparisons between ASC and HOPD groups were drawn with chi-square tests for categorical variables and t-tests for continuous variables. Logistic regression models were created to determine the association between surgical setting and primary outcomes. Rates of 90-day CMS-reportable complications (2.95% vs 2.17%%; p = 0.193), 90-day readmission (4.95% vs 4.25%; p = 0.370) and return to the operating room within 90 days (0.07% vs 0.2%; p = 0.286) were not significantly different between groups. Rate of visits to the emergency department within 7 days was not statistically different between groups (2.57% vs 3.03%; p = 0.458). With the ASC group as reference, no statistically significant association between an outcome and surgical setting was detected after adjusting for confounding factors including comorbidity burden. These findings provide reassurance to providers who perform these procedures in either surgical setting.

Minimally invasive lumbar decompression in an ambulatory surgery center.

BACKGROUND: There is limited data regarding clinical and surgical outcomes of minimally invasive lumbar decompression (MIS LD) as an outpatient procedure. In this context, our purpose is to evaluate a single surgeon's experience with performing MIS LD in the outpatient versus inpatient setting and determining if there are differences in surgical and clinical outcomes. METHODS: Patients undergoing primary, one- to three-level MIS LD were retrospectively reviewed and stratified by surgical setting: ambulatory surgical center (ASC) versus hospital. The cohorts were compared with respect to demographics, perioperative characteristics, complications, postoperative pain and narcotics consumption, and improvements in patient-reported outcomes. RESULTS: Five hundred and nine patients were included: 332 patients underwent surgery at an ASC and 177 patients underwent surgery at a hospital. The ASC patients were younger, more likely to be male, and carry Workers' Compensation insurance. The hospital patients were older, more likely to be diabetic, and had a greater comorbidity burden. Patients undergoing MIS LD in an ASC were less likely to have multi-level procedures and more likely to have decompression with discectomy compared to patients in the hospital cohort. There were two cases of superficial wound infection in the ASC cohort and a single case of a pulmonary embolus in the hospital cohort. Additionally, a total of 28 patients had recurrent herniated nucleus pulposus in the ASC cohort compared to 12 patients in the hospital cohort. There was one case of residual stenosis in the ASC cohort compared to eight cases in the hospital cohort. Both cohorts demonstrated similar preoperative ODI, VAS back pain, and VAS leg pain scores through 12-month follow-up. CONCLUSIONS: MIS LD is a safe and effective procedure in an ASC, however, appropriate patient selection and postoperative protocols are imperative in minimizing complications and optimizing safety and efficacy in the outpatient setting.