Comparison of Patient Outcomes and Cost of Overlapping Versus Nonoverlapping Spine Surgery

doi:10.1016/j.wneu.2017.01.064

World Neurosurgery

Volume 100, April 2017, Pages 658-664.e8

https://doi.org/10.1016/j.wneu.2017.01.064 Get rights and content

Background

Overlapping surgery recently has gained significant media attention, but there are limited data on its safety and efficacy. To date, there has been no analysis of overlapping surgery in the field of spine. Our goal was to compare overlapping versus nonoverlapping spine surgery patient outcomes and cost.

Methods

A retrospective review was undertaken of 2319 spine surgeries (n = 848 overlapping; 1471 nonoverlapping) performed by 3 neurosurgery attendings from 2012 to 2015 at the University of California San Francisco. Collected variables included patient age, sex, insurance, American Society of Anesthesiology score, severity of illness, risk of mortality, procedure type, surgeon, day of surgery, source of transfer, admission type, overlapping versus nonoverlapping surgery (≥1 minute of overlapping procedure time), Medicare-Severity Diagnosis-Related Group, osteotomy, and presence of another attending/fellow/resident. Univariate, then multivariate mixed-effect models were used to evaluate the effect of the collected variables on the following outcomes: procedure time, estimated blood loss, length of stay, discharge status, 30-day mortality, 30-day unplanned readmission, unplanned return to OR, and total hospital cost.

Results

Urgent spine cases were more likely to be done in an overlapping fashion (all P < 0.01). After we adjusted for patient demographics, clinical indicators, and procedure characteristics, overlapping surgeries had longer procedure times (estimate = 26.17; P < 0.001) and lower rates of discharge to home (odds ratio 0.65; P < 0.001), but equivalent rates of 30-day mortality, readmission, return to the operating room, estimated blood loss, length of stay, and total hospital cost (all P = ns).

Conclusions

Overlapping spine surgery may be performed safely at our institution, although continued monitoring of patient outcomes is necessary. Overlapping surgery does not lead to greater hospital costs.

Introduction

Overlapping surgery, also known as simultaneous/concurrent surgery or “running 2 rooms,” recently has garnered significant media attention¹ and prompted a senate inquiry into its safety and efficacy.² In response, Massachusetts General Hospital released a formal statement on its website describing the importance of overlapping surgeries in academic medical centers³ and outlining a policy for their safe implementation.⁴ The American College of Surgeons⁵ and the major neurosurgical societies⁶ also clarified the definition of concurrent versus overlapping procedures. Concurrent surgeries are those in which the critical portion of the procedure occurs simultaneously in 2 separate operating rooms (ORs), whereas overlapping procedures are those in which the primary attending surgeon performs the critical portion of the procedure, but others assist with noncritical elements of the procedure, such as opening and closure (Figure 1).⁶ The neurosurgical professional societies explicitly state that concurrent surgeries are “not appropriate.”⁶ In contrast, overlapping procedures may be performed but should be done in a way that does not “negatively impact the seamless and timely flow of either procedure.”⁶

To support these position statements, there are limited published data on the safety and efficacy of overlapping surgery. Several opinion pieces in the surgical literature have posited that overlapping surgery is safe,7, 8 but the only available data are from a noncontrolled, nonpeer-reviewed description of 418 cases on the Massachusetts General Hospital website⁹ and an unpublished study on 1378 cardiothoracic patients presented at a national meeting.¹⁰ Our institution recently performed a comprehensive analysis of 1219 overlapping versus nonoverlapping vascular neurosurgery cases,¹¹ as well as 7358 overlapping versus nonoverlapping neurosurgery cases.¹² We found longer operative times for overlapping procedures but otherwise equivalent patient outcomes in both analyses.11, 12

To date, there has been no analysis of the safety or efficacy of overlapping surgery in the spine literature. The goal of this study was therefore to compare the patient outcomes and cost of overlapping versus nonoverlapping spine surgeries at our institution.

Section snippets

Materials and Methods

We performed a retrospective analysis of 2319 spine surgeries done by 3 neurosurgery attendings at the University of California, San Francisco (UCSF), who each did ≥50 overlapping surgeries from 2012 to 2015. Patient and surgical data were obtained from the electronic medical record (APeX, EPIC, Inc.). Cost data were from our hospital's internal accounting database. The study was approved by the UCSF IRB #16-19200.

We collected the following variables for each case:

1).
Patient demographics: sex,

Results

Three neurosurgical attendings performed 2319 spine procedures: 848 (36.6%) were overlapping; 1471 (63.4%) were nonoverlapping. There was no significant difference in the age, sex, insurance status, SOI, or ROM of overlapping versus nonoverlapping patients (Table 1). Overlapping patients had more missing ASA data (14.2% vs. 10.7%, P = 0.02; Table 1) but otherwise did not have significantly lower or greater ASA scores than nonoverlapping patients; however, overlapping patients were more likely

Discussion

Our analysis of 2319 spine procedures revealed that urgent spine cases on inpatients and those transferred from other hospitals or EDs were more likely to be done in an overlapping fashion. Otherwise, patient demographics were similar between the overlapping and nonoverlapping surgical groups. This finding suggests that overlapping surgery is used by spine surgeons to facilitate timely treatment of patients with more acute conditions, such as acute neurologic deteriorations, hematomas, or wound

Conclusions

Overlapping spine surgery may be performed safely by these 3 surgeons at our institution, although continued monitoring of patient outcomes is necessary. Overlapping surgery does not lead to greater hospital costs.

References (13)

J. Abelson et al.
Clash in the name of care
J. Saltzman et al.
Overlapping surgeries to face US Senate inquiry
The Boston Globe
(2016)
Massachusetts General Hospital
About Concurrent/Overlapping Surgery Fact Sheet
Massachusetts General Hospital
Perioperative Policy for Concurrent Surgical Staffing of Two Rooms
American College of Surgeons
Statement of Principles
Position Statement on Intraoperative Responsibility of the Primary Neurosurgeon

There are more references available in the full text version of this article.

Cited by (43)

Does Age and Medicare Status Affect Clinical Outcomes in Patients Undergoing Anterior Cervical Discectomy and Fusion?
2022, World Neurosurgery
The objective of this study was to determine if Medicare status and age affect clinical outcomes following anterior cervical discectomy and fusion.
Patients who underwent cervical discectomy and fusion between 2014 and 2020 with complete preoperative and 1-year postoperative patient-reported outcome measures (PROMs) were grouped based on Medicare status and age: no Medicare under 65 years (NM < 65), Medicare under 65 years (M < 65), no Medicare 65 years or older (NM ≥ 65), and Medicare 65 years or older (M ≥ 65). Multivariate regression for ΔPROMs (Δ: postoperative minus preoperative) controlled for confounding differences between groups. Significant was set at P < 0.05.
A total of 1288 patients were included, with each group improving in the visual analog score (VAS) Neck (all, P < 0.001), VAS Arm (M < 65: P = 0.003; remaining groups: P < 0.001), and Neck Disability Index (M < 65: P = 0.009; remaining groups: P < 0.001) following surgery. Only M < 65 did not significantly improve in the Physical Component Score (PCS-12) and modified Japanese Orthopaedic Association (mJOA) score (P = 0.256 and P = 0.092, respectively). When comparing patients under 65 years, non-Medicare patients had better preoperative PCS-12 (P < 0.001), Neck Disability Index (P < 0.001), and modified Japanese Orthopaedic Association (P < 0.001), as well as better postoperative values for all PROMs (P < 0.001), but there were no differences in ΔPROMs. Multivariate analysis identified M < 65 to be an independent predictor of decreased improvement in ΔPCS-12 (β = −4.07, P = 0.015), ΔVAS Neck (β = 1.17, P = 0.010), and ΔVAS Arm (β = 1.15, P = 0.025) compared to NM < 65.
Regardless of age and Medicare status, all patients undergoing cervical discectomy and fusion had significant clinical improvement postoperatively. However, Medicare patients under age 65 have a smaller magnitude of improvement in PROMs.
Commentary: Risk of overlapping surgery in cardiac surgery? Much ado about nothing
2021, Journal of Thoracic and Cardiovascular Surgery
Not without my attending: a survey of patient and family member attitudes and perceptions about concurrent and overlapping surgery
2021, Spine Journal
Citation Excerpt :
After section one was completed, the research assistant administering the survey defined simultaneous surgery, explained the difference between concurrent and overlapping surgery, addressed participants’ questions and concerns, and was available for the duration of the survey to provide clarification on any survey items. The explanation of these terms was done in a standardized manner using diagrams and a preformulated script after question 11 of the survey was completed [21]. Sections two to five all utilized a 5-point Likert scale to assess comfort level with a certain situation or agreement with statement.
Recent media coverage of overlapping surgery has led to several studies investigating public perception of concurrent and overlapping surgery, both of which involve a single attending surgeon working on two separate cases in two separate operating rooms. In concurrent surgery, the critical periods of the surgeries overlap, while in overlapping surgery they do not. The literature revealed a general lack of knowledge about these practices and strong disapproval of their use by the public.
To determine the comfort level of spine surgery patients and their family members toward concurrent and overlapping surgery.
This cross-sectional survey study was performed at an urban, adult academic spine surgery clinic.
Patients and their companions who were waiting to be seen at their initial clinic visit or follow-up visit were approached to participate in the study.
The survey queried respondents’ baseline knowledge of and comfort level with concurrent and overlapping surgery, in addition to comfort level with different levels of surgical trainees on a 5-point Likert scale.
A five-section, 36-item questionnaire was administered by a research assistant to respondents over a 3-month period spanning June 2019 – August 2019. A research assistant described the terms overlapping surgery and concurrent surgery to participants of the survey using diagrams and a preformulated script after self-reported knowledge questions. Statistical analysis was performed using the chi-square test for categorical variables, and Kendall's tau-c rank correlation coefficient with ordinal independent variables for correlations.
Knowledge about concurrent and overlapping surgery was low in our study population (8.22% and 6.16%, respectively). Over half of respondents reported that they felt comfortable with overlapping surgery (58.22%). Most respondents reported that they would like their surgeon to disclose the participation of surgical trainees (residents and fellows) in their surgery (98%). In addition, the 4th and 5th years of surgical training were associated with a significant increase in patient comfort with surgical trainee participation. There was no difference in response distribution between patients versus nonpatients.
Knowledge about concurrent and overlapping surgery remains poor in our study population. Lack of general knowledge about overlapping surgery can be a serious impediment to obtaining informed consent, and further study is required to determine the best methods to raising patient awareness.
Duration of overlap during lumbar fusion does not predict outcomes
2021, Clinical Neurology and Neurosurgery
Citation Excerpt :
Previous studies among multiple subspecialties have found a longer length of surgery, but not an increased risk for adverse outcomes or complications following overlapping surgery [6–9]. Within neurosurgery, studies have reported equivalent or non-inferior outcomes following various neurosurgical procedures [10–15]. Most prior work has exclusively focused on the binary presence or absence of overlap on patient outcomes.
The relationship between degree of surgical overlap and adverse postoperative outcomes remains poorly defined. This study aims to evaluate the impact of increasing duration of overlap on lumbar fusion outcomes.
1302 adult patients undergoing overlapping surgery during single-level, posterior-only lumbar fusion at a multi-hospital, university health system were retrospectively assessed. Amount of overlap was calculated as a percentage of total overlap time. Patients were separated into groups with the most (top 10% of patients) and least amounts of overlap (bottom 40% of patients). Using Coarsened Exact Matching, patients with the most and least amounts of overlap were matched on demographics alone, then on both demographics and attending surgeon. Univariate analysis was performed for the whole population and both matched cohorts to compare amount of overlap to risk of adverse postsurgical events. Significance for all analyses was p-value < 0.05.
Duration of overlap was not associated with outcomes in the whole population, demographic-matched, or surgeon-matched analyses. Before exact matching, patients with the most amount of overlap had a significantly higher CCI score (p = 0.031) and shorter length of surgery (p = 0.006). In the demographic matched cohort, patients with increased overlap had a significantly shorter length of surgery (p = 0.001) only. In the surgeon matched cohort, there were no differences in length of surgery or CCI score.
Duration of surgical overlap does not predict adverse outcomes following lumbar fusion. These results suggest that overlapping surgery is a safe practice within this common neurosurgical indication.
Patients undergoing overlapping posterior single-level lumbar fusion are not at greater risk for adverse 90-day outcomes
2021, Clinical Neurology and Neurosurgery
This study evaluated overlapping surgery on long-term outcomes following elective, single-level lumbar fusion on exact matched patients undergoing surgery with or without overlap.
3799 consecutive adult patients undergoing single-level, posterior-only lumbar fusion over a six-year period at a multi-hospital university health system were retrospectively followed. Reported outcomes included reoperation, emergency department (ED) visit, readmission, overall morbidity and mortality in the 90 days following surgery. Coarsened Exact Matching was used to match patients with and without overlap on key demographic factors. Patients were subsequently matched by both demographic data and by the attending surgeon performing the operation. Univariate analysis was carried out on the whole population, the demographic matched cohort, and demographic and surgeon matched cohort, with significance set at a p-value < 0.05.
Patients with overlap had a longer duration of surgery and were less likely to have an ED visit within 90 days of surgery (p < 0.03) but had no other significant differences. Within the demographic matched cohort and demographic/surgeon matched cohort, there was no significant difference in age, gender, history of prior surgery, ASA score, or CCI score, but patients with overlap had a longer duration of surgery (p < 0.01). Patients did not have significant differences with respect to any morbidity or mortality outcome in either the demographic or surgeon matched cohort.
Patients undergoing overlapping, single-level lumbar fusion were not at greater risk of long-term morbidity or mortality, despite having a significantly longer duration of surgery.
Overlapping Surgery Increases Operating Room Efficiency Without Adversely Affecting Outcomes in Total Hip and Knee Arthroplasty
2020, Journal of Arthroplasty
Several recent studies have demonstrated that overlapping surgeries in total hip (THA) and knee (TKA) arthroplasty do not increase the rates of complications, but whether this practice is cost-effective has yet to be addressed in the literature. The purpose of this study is to determine the effect of overlapping surgery on procedural costs and surgical productivity during THA and TKA.
We identified all patients undergoing primary THA or TKA from 2015 to 2018 by 18 surgeons at a single orthopedic specialty hospital. Procedural and personnel costs were calculated for each case using a time-driven activity-based costing algorithm. Overlap of surgical time by at least 30 minutes was used to define an overlapping procedure. We compared costs and outcomes between overlapping and nonoverlapping procedures, standardizing all costs to 8-hour time blocks. A multivariate regression analysis was performed to determine independent effect of overlapping procedures on costs and outcomes.
Of the 4786 consecutive procedures, 968 (20.2%) overlapped by at least 30 minutes. Although overlapping rooms increased mean operative time by 8.3 minutes (P < .0001) and operating room personnel costs by $80 per case (<.0001), overlapping surgeons could perform significantly more procedures per 8 hours (7.6 vs 6.4; P < .0001), increasing total 8-hour profit margin by $1215 per procedure. There was no difference in 90-day readmission rate, length of stay, or rates of discharge home between the groups.
Overlapping noncritical portions of procedures in primary THA and TKA appear to be both a safe practice and an effective strategy.

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: Conflict of interest statement: C.C. Zygourakis is supported by a research fellowship from the UCSF Center for Healthcare Value. The authors report the following financial disclosures: C.C. Zygourakis (Nuvasive, Globus – travel grants to attend resident education courses); M. Keefe (Consultant – Depuy Spine): P.V. Mummaneni (AO Spine - grant, honoraria; Globus – honoraria; Depuy, Thieme publishing – royalty; Springer publishing – royalty; Taylor and Francis publishing – royalty; Spinicity/ISD – stock); C.P. Ames (Grants/Research – DePuy Synthes Spine; Consultant – DePuy, Medtronic, Stryker; Stock/Shareholder – Baxano, Doctor's Research Group; Royalties – Aesculap, Biomet Spine).

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Original ArticleComparison of Patient Outcomes and Cost of Overlapping Versus Nonoverlapping Spine Surgery

Background

Methods

Results

Conclusions

Introduction

Section snippets

Materials and Methods

Results

Discussion

Conclusions

Clash in the name of care

Overlapping surgeries to face US Senate inquiry

The Boston Globe

About Concurrent/Overlapping Surgery Fact Sheet

Perioperative Policy for Concurrent Surgical Staffing of Two Rooms

Statement of Principles

Position Statement on Intraoperative Responsibility of the Primary Neurosurgeon

Original Article
Comparison of Patient Outcomes and Cost of Overlapping Versus Nonoverlapping Spine Surgery