Introduction: In this era of escalating healthcare cost and universal pressure of improving efficiency of care, attention has increased on outpatient surgeries and ambulatory surgery centers(ASCs). Growing evidence supports the safety and effectiveness of ASCs for lumbar decompression and diskectomy. However, there is scarcity of evidence for ACDF in an ASC setting. Therefore, we analyzed a prospective quality improvement registry(National Surgical Quality Improvement Program-NSQIP) to determine if there is a difference in surgical safety between outpatient vs. inpatient ACDF.
Methods: Patients undergoing ACDF(2005-2011) were identified based on the primary CPT codes from the NSQIP database. Patients were divided into two cohorts and, peri-operative outcomes and 30-day morbidity was compared. Propensity score matching and multivariate logistic regression analysis was used to adjust for confounding factors and identify predictors of peri-operative outcomes and morbidity.
Results: A total of 7,288 ACDF cases were identified (Inpatient=6,120, Outpatient=1,168). Unadjusted rates of major morbidity (0.94% vs. 4.5%; p<0.001) and return to OR within 30 days (0.3% vs. 2.0%; p<0.001) were significantly lower in outpatient vs. inpatient ACDF. A total of 1,442 cases (Inpatient=650, Outpatient=792) were propensity matched based on 32 covariates, Table 1. After propensity matching, rates of major morbidity and return to OR were still lower in outpatient ACDF, Table 2. Adjusted comparison using multivariate logistic regression also demonstrated same results: patients in outpatient ACDF had 58% lower odds of having a major morbidity and 80% lower odds of return to OR within 30 days.
Conclusions: In a nation-wide, prospective quality improvement registry representing more than 250 hospitals, 1-3 level outpatient ACDF can be safely performed as it was associated with significantly lower surgical morbidity and return to OR within 30 days as compared to Inpatient ACDF. In an effort to decrease cost of care, surgeons can safely consider performing ACDF in an ASC environment.
Patient Care: Our results highlight that 1-3 level outpatient ACDF can be safely performed as it was associated with significantly lower surgical morbidity and return to OR within 30 days as compared to Inpatient ACDF
Learning Objectives: At the end of the session, participants should be able to: 1) understand the differences between surgical morbidity in inpatient vs outpatient ACDF; 2) Identify that 1-3 level ACDF can be safely performed in an ASC setting.