The most common form of research examines at a single procedure or type of procedure and reviews its outcomes, such as safety, efficacy and patient satisfaction. This can allow the research to glean information about patient selection protocols, site of service recommendations or general procedure quality metrics.
Outpatient and Inpatient Single-level Cervical Total Disc Replacement: A Comparison of 30-day Outcomes
Published in SPINE, January 2019
This study from a research team at the Emory University Department of Orthopedic Surgery looked at patients who underwent one kind of surgery: single-level cervical total disc replacement (TDR) surgery. The study authors then compared 30-day postoperative outcomes such as complication rate and reoperation rate between those patients who were treated as outpatients and those who were treated on an inpatient basis. The authors found no difference in any of the 30-day measures and offered the study as support that TDR can be performed safely in outpatient settings.
How it impacts ASC advocacy: As technology and surgical technique advance, complex procedures will shift from the inpatient to outpatient space. In regard to spine procedures specifically, evidence suggests that the volume of spinal procedures has grown drastically since 1990, likely the result of an aging population overall. The proportion of such surgeries performed as outpatient has grown significantly as well due to the development of better, minimally invasive surgical techniques. While this migration is encouraging for the outpatient surgery sector, patient safety must remain paramount. The proliferation of research showing safe performance of outpatient spine procedures has directly translated to the Centers for Medicare & Medicaid Services (CMS) reimbursing for more of these procedures in hospital outpatient departments (HOPD) and ASCs.
A less common but more useful category of study examines outcomes at ASCs specifically in an effort to reach conclusions about the ASC as a site of service rather than the procedure itself. The following example is especially pertinent, with CMS proposing to take total hip arthroplasty (THA) off the Medicare Inpatient-Only (IPO) list in the CY 2020 OPPS/ASC Proposed Payment Rule:
Outpatient Total Hip Arthroplasty Performed at an Ambulatory Surgery Center versus Hospital Outpatient Setting: Complications, Revisions, and Readmissions
Published in The Journal of Arthroplasty, July 2019
This study looked at almost 1,000 outpatient THA episodes performed by two surgeons from 2013 to 2018, with more than 300 THAs performed in an ASC and the remaining 600 performed in the HOPD. The authors state that to their knowledge it is the first study to directly compare safety profiles of patients undergoing outpatient THA in a freestanding ASC versus HOPD. However, it is important to note that the authors did not match underlying patient comorbidities and even acknowledge that ASC patients were younger and healthier (possibly due to patients over 65 being ineligible due to lack of Medicare reimbursement). The authors found no difference in 90-day complications, revisions, reoperation, readmission or emergency department (ED) visits and conclude that with appropriate patient selection protocols, THA can be safely performed on an outpatient basis at ASCs.
How it impacts ASC advocacy: As previously mentioned, CMS proposed that THA be removed from Medicare’s IPO payment list in 2020. Although this will not make the procedure eligible for reimbursement for Medicare patients in ASCs, it is the first step on that path by allowing for reimbursement in other outpatient sites of service. Although many ASCs have been performing total joint replacements and similar complex orthopedic procedures for years, CMS still does not pay for it in the ASC setting. Advocacy to CMS in support of moving complex surgical procedures to the ASC space must definitively show patient outcomes at ASCs are equal to or better than other sites of service. A study such as this one shows that surgeons are already performing THA in ASCs with no adverse outcomes, and that proper patient selection protocols make the procedure a good candidate for ASC payment by Medicare.