Transitioning to the Ambulatory Surgical Center, Part 2: Surgeon Perspective and Hurdles Faced

The first part of this series on ambulatory surgical center (ASC) utilization in spine surgery focused on the patient perspective. The article highlighted the myriad benefits that patients receive with regard to safety, surgical efficiency, cost efficacy, and additional conveniences that have affected the rising popularity of ASCs. As the concluding part of this two-piece series, the present article will examine the surgeon’s perspective. While many positive aspects of ASCs benefit both patients and surgeons alike, such as safety and surgical efficacy, this article will focus on those benefits and challenges exclusively accorded to and faced by the surgeon. These unique aspects include increased autonomy, greater surgical cost efficacy, and both technological and personnel efficiencies.

One of the largest draws in transitioning to ASCs for surgeons is the significant increase in managerial and surgical autonomy when compared to a hospital-based system. The majority of ASCs (approximately 65%) are owned in entirety by physicians.[1] From a managerial perspective, surgeons are able to control macro-level decisions with regard to insurance agreements, utilization of space, and efficient distribution of operating room time—factors that would generally be decided by administrative staff in the hospital setting. Furthermore, surgeons are in total control of hiring optimal staff that improve the flow of the surgical process from admission to discharge. As a result, the environment of the ASC is highly adaptable to meet the needs of the surgeons and thus optimize patient care. In the event surgeons would choose to defer the more mundane requirements of managing an ASC, surgeons are able to partner with experienced ASC companies for assistance with these tasks. In this model, physician-owners are able to prioritize the clinical environment and maintain autonomy while allowing the ASC company to interface with insurance and support staff contracting companies.[1]

In the previous article, the cost savings for patients was highlighted at approximately $3,000 per lumbar decompression procedure; however, this decrease in cost is highly reflective of downstream benefits from a surgeon-managed practice.[2–5] As part- or full-owners, surgeons are able to make small changes in the clinical setting, fine-tuning needs to the surgeon group to reduce inefficiencies. Two of these changes are (1) an increased proportion of operating room time per day as a result of improved room turnover rate and (2) decreased overhead through limiting unnecessary equipment purchases. Furthermore, in situations where inefficiencies are identified, surgeon-owners are able to make small changes to improve flow without bureaucratic delays or conflicts with administrative staff. Thus, routine case-cost analyses can allow surgeons to quickly identify and adapt to improve the clinical setting, lowering costs for patients and surgeons alike.[6]

In addition to constant adaptation of the clinical environment, ASCs allow spine surgeons to reduce overhead through technological efficiencies including radiological requirements, innovative intraoperative neuromonitoring techniques, and robotics and navigation. In ASC groups, it is important for surgeons to identify the necessary radiological equipment that meets the needs of the group without resulting in excess waste. By properly identifying this need, the right equipment can be shared without delays in patient care, increased operating room time, or overly idle devices that decrease cost efficacy. As indications for ASC care expand, surgeons also require technologies that allow for increasing productivity and safety in complicated cases.[7–10] As an example, the lateral lumbar interbody fusion (LLIF) has been demonstrated to be a highly effective procedure for restoring sagittal parameters and achieving fusion with placement of a large interbody device.[11–13] However, LLIF is performed via a transpsoas approach in which the identification of the femoral nerve is required in order to prevent injury.[12]

Currently, a variety of intraoperative neuromonitoring techniques, including a combination of electromyography and motor or somatosensory evoked potentials, are utilized in this process.[14] Such techniques require additional staff, increased operative room setup time, and inherent equipment expenses. Newer technologies on the horizon, including real-time ultrasound devices that allow for quick identification of the vascular and neural elements, may further improve productivity and safety concurrently.[14,15] Additionally, advances in robotics and intraoperative navigation have the potential to decrease operating room times and reduce complication rates.[16] Utilization of these technologies in the ASC setting may vary depending on surgical group size, as the benefits of robotics may not be cost effective in smaller groups if not used routinely by multiple providers. While robotics have demonstrated significant benefits, ownership may not outweigh upfront purchasing and maintenance fees if not routinely utilized.

Additionally, the equipment requires a large amount of real estate even when not in use, further limting utility in a smaller practice. As the final key to maintaining safety while optimizing productivity, the ASC setting offers surgeons a variety of personnel efficiencies. In order to be productive, surgeons rely on support staff, including circulating and scrub nurses, physician assistants, and medical assistants for rapid room turnover. Furthermore, anesthesiologists and their relevant support staff need to be reliable to safely induce and withdraw anesthesia in an efficient manner. Such consistent reliability requires a clear understanding between surgeons and anesthesiologists with regard to patient selection criteria and perioperative protocols. Patient selection criteria for ASCs generally include low comorbidity burden, lack of obstructive sleep apnea, manageable body mass index (i.e., ≤38), and a negative history of cardiac events. Additionally, multimodal analgesia protocols can minimize anesthesia-related complications throughout the perioperative period.[17–19] Outside of the clinical care setting, surgeons are also reliant on office personnel, including office assistants, case managers, and billing professionals. Appropriate hiring independently by surgeons or through experienced ASC companies may increase nonclinical efficiencies.

Overall, ASCs offer a substantial array of benefits to both patients and surgeons. Concluding this two-part series, it is important to highlight the backbone of ASCs that underlie these efficiencies. Surgeon autonomy is paramount. Surgeon autonomy allows for a reduction in redundancies while improving patient safety and access to care. As the popularity of ASCs continues to rise, identifying other factors that lead patients and surgeons to choose the ambulatory setting is of great importance. n

References

1. Badlani N. Ambulatory surgery center ownership models. J Spine Surg. 2019;5(Suppl 2):S195-S203.

2. Malik AT, Xie J, Retchin SM, et al. Primary single-level lumbar microdisectomy/decompression at a free-standing ambulatory surgical center vs a hospital-owned outpatient department-an analysis of 90-day outcomes and costs. Spine J. 2020;20(6):882-887.

3. Lewandrowski KU. Incidence, management, and cost of complications after transforaminal endoscopic decompression surgery for lumbar foraminal and lateral recess stenosis: a value proposition for outpatient ambulatory surgery. Int J Spine Surg. 2019;13(1):53-67.

4. Pendharkar AV, Shahin MN, Ho AL, et al. Outpatient spine surgery: defining the outcomes, value, and barriers to implementation. Neurosurg Focus . 2018;44(5):E11.

5. Purger DA, Pendharkar AV, Ho AL, et al. Analysis of outcomes and cost of inpatient and ambulatory anterior cervical disk replacement using a state-level database. Clin Spine Surg. 2019;32(8):E372-E379.

6. Corporate SIS. ASC case costing: where should surgery centers start? Accessed January 19, 2023. https:// blog.sisfirst.com/asc-case-costingwhere-should-surgery-centers-start

7. Best MJ, Buller LT, Eismont FJ. National trends in ambulatory surgery for intervertebral disc disorders and spinal stenosis: a 12-year analysis of the National Surveys of Ambulatory Surgery. Spine . 2015;40(21):1703-1711.

8. Chin KR, Pencle FJR, Coombs AV, Packer CF, Hothem EA, Seale JA. Eligibility of outpatient spine surgery candidates in a single private practice. Clin Spine Surg. 2017;30(10):E1352-E1358.

9. Helseth Ø, Lied B, Halvorsen CM, Ekseth K, Helseth E. Outpatient cervical and lumbar spine surgery is feasible and safe: a consecutive single center series of 1449 patients. Neurosurgery 2015;76(6):728-737; discussion 737-738.

10. Basques BA, Ferguson J, Kunze KN, Phillips FM. Lumbar spinal fusion in the outpatient setting: an update on management, surgical approaches and planning. J Spine Surg. 2019;5(Suppl 2):S174-S180.

11. Teng I, Han J, Phan K, Mobbs R. A meta-analysis comparing ALIF, PLIF, TLIF and LLIF. J Clin Neurosci. 2017;44:11-17.

12. Mobbs RJ, Phan K, Malham G, Seex K, Rao PJ. Lumbar interbody fusion: techniques, indications and comparison of interbody fusion options including PLIF, TLIF, MI-TLIF, OLIF/ATP, LLIF and ALIF. J Spine Surg. 2015;1(1):2-18.

13. Salzmann SN, Shue J, Hughes AP. Lateral lumbar interbody fusion—outcomes and complications. Curr Rev Musculoskelet Med. 2017;10(4):539-546.

14. Singh K, Cha EDK, Lynch CP, et al. Device profile of SonoVision ultrasound system: efficacy and safety for lateral approach spinal surgery. Accessed October 20, 2022. https://journaloei. scholasticahq.com/article/27576.pdf

15. Carson T, Ghoshal G, Cornwall GB, Tobias R, Schwartz DG, Foley KT. Artificial intelligence-enabled, real-time intraoperative ultrasound imaging of neural structures within the psoas: validation in a porcine spine model. Spine . 2021;46(3):E146-E152.

16. D’Souza M, Gendreau J, Feng A, Kim LH, Ho AL, Veeravagu A. Robotic-assisted spine surgery: history, efficacy, cost, and future trends. Robot Surg. 2019;6:9-23.

17. Jenkins NW, Parrish JM, Nolte MT, et al. Multimodal analgesic management for cervical spine surgery in the ambulatory setting. Int J Spine Surg. 2021;15(2):219-227.

18. Bohl DD, Louie PK, Shah N, et al. Multimodal versus patient-controlled analgesia after an anterior cervical decompression and fusion. Spine . 2016;41(12):994-998.

19. Mathiesen O, Dahl B, Thomsen BA, et al. A comprehensive multimodal pain treatment reduces opioid consumption after multilevel spine surgery. Eur Spine J. 2013;22(9):2089-2096.