Lightning Podiums: Smorgasboard - Room 802B

Presented by: P. Passias

Author(s):

P. Passias(1), G. Poorman(1), R. Maloney(1), S. Horn(1), C. Varlotta(1), F. Segreto(1), N. Frangella(1), B. Diebo(2), C. Wang(1), J. Moon(1), M. Gerling(1)

(1) New York University Langone Orthopedic Hospital, Division of Spinal Surgery, New York, NY, United States
(2) SUNY Downstate Medical Center, Department of Orthopaedic Surgery, Brooklyn, NY, United States

Abstract

Introduction: Anterior cervical discectomy and fusion (ACDF) is a common procedure used to treat cervical herniated discs and degenerative disc disease. Though recent care pathways have increased interest in performing ACDF procedures in the outpatient setting at ambulatory surgery centers (ASC), few studies have drawn direct comparisons with the inpatient hospital setting. Large databases can offer several advantages in this type of analysis with their ability to capture a broader geographical distribution with substantially larger statistical power. There exists no studies using large cohort databases comparing ACDF procedures performed in an outpatient vs hospital setting. Our purpose, therefore, was to compare length of stay, cost, and complications between patients undergoing ACDF in outpatient ASC and inpatient hospital settings.

Methods: The New Jersey State Ambulatory Surgery Database (NJSASD) and National Inpatient Sample (NIS) databases were queried for patients age ≥18 with a primary cervical diagnosis that underwent anterior cervical discectomy and fusion (ACDF) procedures (1-2 levels) between the years 2005-12. Patients from the NJSASD databases constituted the outpatient ASC cohort and patients from the NIS database constituted the hospital cohort. NJSASD and NIS patients were propensity score matched based on age, gender, diabetes, coronary artery disease, and chronic kidney disease. Patient demographics, length of stay, total charges, and complications (dysphagia, nervous system, cardiac, respiratory, digestive, urinary, PVD, device-related, shock, hematoma, puncture, infection, anemia, ARDS, PE, and DVT) were recorded and analyzed for significant differences between the two cohorts using Student's t-tests and Pearson's chi-squared tests.

Results: 2,205 outpatients were compared with 2,205 matched inpatients. Average age was 52.13, 51.9% were female, 82.2% white race, and 87.1% performed as elective cases. Due to matching, there were no significant difference in baseline demographics or comorbidities, however, there was a larger proportion of two-level ACDFs in the NIS cohort (NIS 10.8% vs. NJSASD: 7.6%, p< 0.001). NIS had overnight stays 98.6% of the time, as opposed to NJSASD cases who stayed overnight 17.7% (p< 0.001). Inpatient procedures incurred significantly higher charges compared to outpatient procedures ($44,233.08 vs $34,729.82, p< 0.0001). Complications were much more frequent in the hospital setting (4.9% inpatient versus 0.5% outpatient). Complications that were more prevalent in hospitals as compared to outpatients included dysphagia, nervous system, cardiac, respiratory, digestive, urinary, device-related, hematoma, puncture, infection, anemia, ARDS, PE, and DVT (all p< 0.05).

Conclusions: Patients undergoing ACDF procedures performed between 2005 and 2012 were matched in two large databases to analyze operative and post-operative data in the inpatient hospital setting compared with the outpatient ASC setting. Within the limitations inherent to database studies, we found that hospital based ACDF surgery had a higher length of stay, incurred greater charges, and experienced a greater number of complications, despite controlling for comorbidities, age, and gender. These disparities are tempered by a slightly higher frequency of two-level ACDFs in the hospital setting and possible differences in database reporting. These results suggest significant advantages for outpatient ACDF procedures including an acceptable safety profile.