Due to the ongoing trend toward reducing health care expenditure in the US, technological improvements that simplify and increase the safety of procedures, as well as growing patient demand for increased convenience and accessibility to treatment, there continues to be a shift in the types of procedures performed in the hospital versus nonhospital setting. Many low-risk, high-cost surgical procedures that had traditionally been performed in the hospital setting are now increasingly being performed in ASCs. Orthopedic procedures, such as spine surgeries, are no exception, representing a rapidly growing field in ASCs across the US. For example, orthopedic procedures performed in the inpatient setting are expected to decline by 3% in the next decade, but are projected to rise by 35% in the outpatient setting during the same period.
At NASS 2018, some sessions were dedicated to showing surgeons how to adapt their practices to increase the volume of spine procedures performed in ASCs; current assessments estimate that up to 50% of spine procedures can be performed in ASCs, though most of these would be single-level surgeries, which are considered lower-risk procedures. This would largely rely on the use of minimally invasive techniques, as well as a heightened emphasis on pre- and postoperative techniques to further reduce procedure times, including the reduction of pain medication administration, which would in turn decrease the time that patients would be required to remain in a bed. In addition, one-day “awake surgeries” are becoming increasingly safe and accessible; these procedures have improved drastically in recent years due to the use of smaller incisions, which leads to less pain and allows the application of regional anesthesia in a smaller area, ultimately improving postoperative recovery times. These developments have reduced mean length of stay to 1.4 days, which is much lower than the 4.2 and 3.5 days associated with conventional and minimally invasive spine surgeries, respectively.
At present, most spine revenues generated in ASCs are associated with cervical spine products because these are mostly used in single-level procedures, and biologics—which are often used along with spinal implants—also account for a sizable proportion of ASC revenues; thoracolumbar spine procedures, many of which are multilevel surgeries, have thus far seen limited penetration into the ASC space, due primarily to the added complexity and risk involved in these surgeries.
Some limitations on the shift of spine procedures toward ASCs include the fact that a majority of multilevel procedures are still considered too risky to be performed in this setting; as a result, most ASC spine procedures continue to be of the single-level variety. Going forward, it is expected that a larger proportion of spine procedures will be performed in ASCs; this will be supported by the 2017 addition of a number of spine CPT codes to the CMS ASC covered list, which has made payment available for interspinous process decompression, two-level anterior cervical discectomy and fusion, anterior interbody devices, a number of anterior and posterior spinal fusion instrumentation, and numerous autografts for spine surgery, among others.
The ASC space is highly competitive, with more than 50 competitors reporting revenues in ASCs. Interestingly, spinal technologies giant Stryker holds a larger share of the ASC market than its hospital counterpart, which is a direct result of to the company’s Ascential program. Through this program, Stryker delivers on-demand, single-use products to ASCs in accordance with scheduled procedures, which significantly reduces the burden of inventory management for ASCs and further reduces the overall cost of procedures. Companies looking to capitalize on the shift toward ASCs would be wise to adopt similarly strategic approaches to their relationships with these centers.
With that said, however, most spine procedures continue to be performed in hospital settings, and the vast majority of spine revenues is still generated in hospitals. However, as safety measures are further established and preoperative patient selection and referral patterns continue to improve, more complex procedures will increasingly be performed in ASCs, and revenues generated in these settings are therefore expected to rise substantially going forward.
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