Eric Lamoutte and Kern Singh (Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, USA) discuss results of their recent study examining whether or not day of surgery affects length of stay and hospital charges following lumbar decompression. While they found “no statistical significance” with respect to the scheduling of minimally invasive lumbar decompression, the investigators believe it remains an important topic to investigate, as orthopaedic sub-specialities have found increased in length of stay and associated costs when surgery occurs later in the week.
In the current value-based healthcare climate, there is increasing focus on minimising medical expenditures without compromising the quality of care.5 However, in order to reform the delivery of care in a cost-effective manner, the factors that increase expenses must be identified and reduced. Although unnecessary tests and procedures may be seen as drivers in increasing medical expenditures, hospital length of stay has been recently identified as one of the leading factors contributing to the financial burden.1,2
Spine surgery has been determined to be one of the most expensive surgical interventions on a per-case basis.3,4
Surgeons continually strive to minimise the gap in costs between other sub-specialty procedures and spine surgery, while maintaining maximum efficiency and improving the quality of care. The switch from traditionally open procedures to the alternative minimally invasive approach has significantly minimised the length of stay and costs to the patient and hospital.6,7 However, specific surgical scheduling factors may also play a role in increased length of stay and ensuing costs, as demonstrated by studies evaluating hip fractures and total joint arthroplasties. In these investigations, the surgeries performed earlier in the week were associated with reduced lengths of stay and subsequent expenditures.8-11 The role of surgical scheduling on length of stay and associated costs has not been evaluated in spinal procedures such as minimally invasive lumbar decompression (MIS LD). Thus, the aim of our investigation is to determine whether there is an association between the day of surgery and length of stay and hospital costs after a primary MIS LD.
A prospectively-maintained surgical database was retrospectively reviewed for patients that underwent primary, 1–3 level MIS LD for degenerative pathology from 2008–2017. We classified lumbar decompression as any combination of laminectomies, facetectomies, foraminotomies, and/or partial discectomies. All of the surgeries were performed by a single surgeon at a single academic medical center. We grouped patients undergoing MIS LD according to the timing of their procedures: (1) early in the week (Monday/Tuesday) or (2) late in the week (Thursday/Friday). A total of 717 patients were included in the analysis. 420 (58.6%) patients were in the early surgery cohort and 297 (41.4%) were in the late surgery cohort.
The demographic and baseline characteristics included age, gender, body mass index, smoking status, and comorbidity index. Perioperative variables assessed included operative levels, operation time, estimated blood loss, and length of hospital stay. We determined discharge from the hospital by pain management, ability to ambulate, and voluntary bladder control. Direct hospital costs were obtained from our institution’s billing department and were expressed as total costs. Various factors contributed to the total costs including surgical expenses, blood transfusions, and services from cardiology, emergency room (ER), radiology, laboratory, nursing unit, intensive care unit (ICU), pharmacy, rehabilitation (physical, occupational, or speech therapy), and other miscellaneous expenditures.
The results of this study demonstrated that patients undergoing an MIS LD early in the week have similar lengths of hospital stay compared to those undergoing surgery towards the end of the week. Direct hospital costs were also determined to be similar amongst patients with no differences in when they had their surgery in the week. Furthermore, our cost breakdown analysis demonstrated no difference between cohorts including surgical fees as well as laboratory, nursing, radiology, therapy, and medical sub-specialties fees. Although this particular investigation demonstrated no statistical significance with respect to the scheduling of MIS LD, we believe it remains an important topic to investigate, as other orthopaedic sub-specialties have found increases in length of stay and associated costs when surgery occurs later in the week.
There are several possibilities that could explain why the scheduling of MIS LD during the week displayed minimal effect on length of stay and direct hospital costs. When compared to traditional open spine procedures, minimally invasive techniques are proven to have shorter operative time, less blood loss, and a quicker recovery.12 Due to the minimally invasive nature of the procedure, patients undergoing MIS LD on average suffer drastically reduced pain and are less restricted in mobility in the early postoperative period, allowing for same-day ambulation in most cases. This could be an explanation for the lack of necessity for physical and occupational therapists in the immediate postoperative course. The main cost-driving factor in the total hospital charges is directly related to surgical services, which has little procedural variation in this investigation. Additionally, since MIS LD is mostly a same-day procedure, cohorts experience similar lengths of stay with minimal variation in postoperative hospital course. Therefore, there was no significant difference in costs associated with nursing, physical therapy, and other typical postoperative services. Thus, at this time, there are no recommended changes to scheduling during the week for patients undergoing MIS LD.
There are some strengths and limitations to this study. All surgeries were performed by a single surgeon at a single academic medical center, resulting in a consistency of care. However, the retrospective nature of this study may have introduced an element of selection bias. Additionally, the standard discharge protocol at our institution involves social work being contacted and discharge documents being completed in a timely manner before the weekend. We understand that our discharge protocol may not be generalizable to other institutions. It is important that this study is replicated at other institutions, perhaps as a multi-institutional study, to further understand the effect that surgery scheduling has on length of stay and direct hospital costs for patients undergoing MIS LD.
1. Newman JM, Szubski CR, Barsoum WK, et al. Day of Surgery Affects Length of Stay and Charges in Primary Total Hip and Knee Arthroplasty. J Arthroplasty 2017;32:11-5.
2. Lilly R, Siljander M, Koueiter DM, et al. Day of Surgery Affects Length of Hospitalization for Patients Undergoing Total Joint Arthroplasty Discharged to Extended Care Facilities. Orthopedics 2018;41:82-6.
3. Missios S, Bekelis K. Hospitalization cost after spine surgery in the United States of America. J Clin Neurosci 2015;22:1632-7.
4. Kazberouk A, Sagy I, Novack V, et al. Understanding the Extent and Drivers of Interphysician Cost Variation for Spine Procedures. Spine (Phila Pa 1976) 2016;41:1111-7.
5. Resnick DK, Tosteson AN, Groman RF, et al. Setting the equation: establishing value in spine care. Spine (Phila Pa 1976) 2014;39:S43-50.
6. Al-Khouja LT, Baron EM, Johnson JP, et al. Cost-effectiveness analysis in minimally invasive spine surgery. Neurosurg Focus 2014;36:E4.
7. Phan K, Hogan JA, Mobbs RJ. Cost-utility of minimally invasive versus open transforaminal lumbar interbody fusion: systematic review and economic evaluation. Eur Spine J 2015;24:2503-13.
8. Ricci WM, Brandt A, McAndrew C, et al. Factors affecting delay to surgery and length of stay for patients with hip fracture. J Orthop Trauma 2015;29:e109-14.
9. Keswani A, Beck C, Meier KM, et al. Day of Surgery and Surgical Start Time Affect Hospital Length of Stay After Total Hip Arthroplasty. J Arthroplasty 2016;31:2426-31.
10. Muppavarapu RC, Chaurasia AR, Schwarzkopf R, et al. Total joint arthroplasty surgery: does day of surgery matter? J Arthroplasty 2014;29:1943-5.
11. Malik AT, Khan S, Ali A, et al. Total Knee Arthroplasty: Does Day of Surgery Matter? Clin Med Insights Arthritis Musculoskelet Disord 2018;11:1179544117754067.
12. Banczerowski P, Czigleczki G, Papp Z, et al. Minimally invasive spine surgery: systematic review. Neurosurg Rev 2015;38:11-26; discussion
Kern Singh is a professor of Orthopaedic Surgery at Rush University Medical Center (Chicago, USA).
Eric Lamoutte is a research assistant for Kern Singh at Rush University Medical Center.