The trend of moving medical procedures from hospitals to outpatient settings is picking up speed in almost every realm of health care.
Driven by advancements in medical technology, changes in reimbursement policies, and patients looking for less invasive and more cost-effective care options, ambulatory surgery center (ASC) operators are at a unique precipice with the opportunity to expand their care networks.
Cardiovascular procedures have seen a significant increase in being performed at ASCs. Minimally invasive cardiac procedures, such as diagnostic cardiac catheterization, non-acute percutaneous coronary interventions (PCI), and the implantation of defibrillators and pacemakers, can be done in an outpatient setting.
Similarly, complex spine surgeries are now frequently done in ASCs. The trend also includes joint replacements and arthroscopic surgeries, which leverage minimally invasive techniques to allow for quicker recovery times.
ASC News dove into the logistics of four different kinds of procedures now being performed in an outpatient setting, to learn more about the implications for patients and health systems, and what ASC operators can do to prepare to offer new kinds of care in their facilities.
Liver surgery
Researchers have confirmed that robotic hepatectomy, or liver surgery, can be performed safely as an outpatient procedure. This innovation offers a less invasive option with quicker recovery times, opening new possibilities for ASCs.
A study published in the Journal of the American College of Surgeons in June found that the readmission rate of open liver surgery is 20% to 25% at most major cancer centers. Yet the readmission rate for robotic hepatectomy was only 1.6% in a retrospective analysis of data — meaning that patients who received robotic liver surgery fared much better.
The lead researcher of the study said that while the idea is new, robotic hepatectomies are ideal for ambulatory surgery centers.
“Most liver surgeons, even [those that are] doing it robotically, aren’t thinking outpatient yet, and we are trying to get them to think that way,” Dr. Yuman Fong, senior author of the study, told ASC News.
Indeed, robotic liver surgery, particularly in an outpatient setting, is still nascent, with few papers published on the topic. Yet that will all be changing in the near future, Fong said.
“It’s the same cost as any other robotic operation … ,” Fong said. “From a surgery standpoint, it’s no different than doing a robotic inpatient liver operation, except for the fact that instead of being in the hospital seven to 10 days after surgery, we are now starting to think that there is a subset of patients that could go home the same day or the next day.”
There are now multiple types of surgical robots, including intuitive surgical robots, coming on the market. Most robotic liver surgeries are performed with Intuitive robots, particularly in ASCs, where workflows are more straightforward, Fong said.
“That’s been really helpful for patients for a number of reasons because most patients really don’t want to be in the hospital,” he said. “We can actually find all those cases that should be in the ASCs, have folks go home, and then be able to sleep in their own bed, eat out of their own fridge and recover faster. That’s the bottom line.”
The key to success lies in patient selection and the capabilities of the surgical team, he added.
“What we have found is that the selection criteria, in general, should be minor liver surgeries,” he said. “Three out of seven patients had some major liver resections there. We think, in general, people should consider minor liver surgeries as the No. 1 option. That would be two segments or less of the liver in terms of removal of the total amount of liver.”
For ASC operators, this study signifies a potential shift in the landscape of liver surgeries.
“Many hospitals now have outpatient surgery centers with extended stay capabilities,” Fong said. “In the near future, it’s going to be in ambulatory surgery centers. They just need to have the expertise of the liver surgeon who can perform safe liver surgery and the capability to monitor patients overnight if necessary.”
One of the primary concerns with liver surgery is the risk of bleeding. While some outpatient liver surgeries are performed without blood banking capabilities, Fong said that most minor liver resections no longer require cross-matching for blood.
“Certainly, having the ability to keep patients overnight would be nice if there was any concern about their recovery,” he added.
The future of robotic liver surgery in ASCs looks promising, with an estimated 25% of all robotic liver surgeries potentially suitable for outpatient settings.
“The days of giant operations in hospitals as the only way to cure cancer are over,” he stated. “The ability to perform many of these operations in ASCs provides quicker recovery and the opportunity for patients to sleep in their own beds and eat from their own fridge.”
For ASC operators, this development presents an exciting opportunity to expand their services and improve patient outcomes.
“More cures, less invasive — that’s where it’s all heading,” Fong said.
Cardiovascular procedures
Cardiovascular procedures are increasingly being performed in ASCs, driven by technological advancements and data demonstrating safety and efficacy.
With over 121.5 million heart disease diagnoses annually in the U.S. and only 6.5 million receiving vascular interventions, ASCs are poised to play a crucial role in transforming cardiovascular care.
The shift began around 2018 with diagnostic heart catheterizations and gained momentum in 2020 when CMS added PCIs to its covered procedure list. This move, supported by major cardiology societies, facilitated the expansion of complex cardiovascular procedures in ASCs.
Extensive data collection by cardiologists has proven that many cardiovascular procedures can be safely performed in ASCs without the need for overnight hospital stays. This includes demonstrating the safety of same-day discharges and the efficacy of procedures performed without on-site cardiothoracic surgery support.
The U.S. cardiology procedures market is expected to reach $92.32 billion by 2030, with ASCs playing a significant role. To integrate cardiovascular care successfully, ASC operators must invest in skilled staff, advanced equipment and proper accreditation. Reimbursement models, particularly from CMS and private payers, also support this transition by reducing costs compared to hospital settings.
State regulations vary, with states like Arizona, Texas and Florida having more lenient policies that foster ASC growth.
“This is one thing that is sort of helpful about the country; you can look at places that are doing it, and we can learn from each other,” Dr. Sam Jones, a cardiologist with the Chattanooga Heart Institute, told ASC News. “In Arizona and Texas, for example, you may see more ASCs. The state of Florida is another state that typically has more ASCs, and you may see less regulation in those states.”
Advanced spinal surgeries
The shift of complex spinal surgeries from hospitals to ASC is also gaining momentum, driven by technological advancements and regulatory changes.
ASCs offer significant cost savings, with procedures like laminectomies costing almost half compared to hospitals.
This cost-effectiveness, combined with patient satisfaction, technological innovations and legislative support, has facilitated the shift of both minimally invasive and advanced spinal procedures to ASCs.
Previously, outpatient centers handled minor procedures, but now, complex surgeries such as multi-level lumbar fusions and spinal cord stimulations are performed in ASCs. Changes by CMS have allowed more procedures to be covered in outpatient settings, further accelerating this trend.
Technological advancements, including specialized retractors and advanced navigation systems, have made surgeries less invasive, enabling same-day discharges. Robotic systems like Intuitive’s da Vinci and Stryker’s Mako have transformed spinal surgeries, contributing to the market growth of robotic surgery technology.
With their specialized focus, ASCs offer numerous benefits, operators told ASC News. Staff at these centers are exclusively trained in spinal surgeries, leading to higher expertise and better patient outcomes. The dedicated focus allows for efficient recovery processes, as seen in the higher nursing-to-patient ratio, which enables immediate postoperative care.
For ASCs looking to expand into spinal surgeries, starting with smaller acuity procedures and scaling up is recommended. Proper patient selection is critical, as patients with high risks or multiple comorbidities may not be suitable for ASCs due to their limited capabilities compared to hospitals.
“You just have to use good judgment because it’s kind of a black eye on the surgery center if [hospitalization] is happening with any kind of frequency,” Dr. Michael Burdi, an orthopedic spinal surgeon with Community Orthopedic Medical Group and California Specialty Surgery Center, told ASC News.
Preventative kidney care
Kidney care, particularly treatments for conditions like chronic kidney disease (CKD) and end-stage renal disease (ESRD), is increasingly being provided in ASCs.
One of the major procedures shifting to ASCs is dialysis, specifically peritoneal dialysis and home hemodialysis training. ASCs can offer a more convenient and comfortable environment for patients to receive training on how to manage their dialysis treatments at home.
This transition helps reduce the burden on hospital resources and provides patients with a sense of autonomy and comfort as they manage their chronic conditions, providers told ASC News.
Additionally, minor surgical procedures related to dialysis access, such as the insertion of catheters and creation of arteriovenous fistulas, are also being performed in ASCs. These procedures, typically requiring only local anesthesia and minimal recovery time, are well-suited for the outpatient setting.
Furthermore, the outpatient model for kidney care aligns with the medical expert’s growing emphasis on preventive care and early intervention. And there are operators riding this wave.
Executives at a new center in Tampa, Florida, developed in partnership with Florida Kidney Physicians (FKP), said they aim to transform kidney care from reactive to proactive.
“We are seeing a downward trend in the number of hospitalizations since we opened the center,” Dr. Shyam Uttamchandani, FKP chief financial officer and nephrologist, told ASC News. “This means that patients are staying healthier, they’re staying out of the hospital, and we are preventing some of these crises from happening.”
The 10,000-square-foot facility, featuring six operating rooms, focuses on advanced vascular treatments for end-stage kidney disease patients and preventative care, such as regular monitoring, dietary counseling, and medication management.
The Tampa ASC has already demonstrated success in reducing hospitalizations, with a reported 10% to 20% decrease in access-related hospital stays. This proactive approach to kidney care ensures better patient outcomes and continuity of care, reinforcing the value of ASCs in managing chronic kidney disease.
“Right now, the majority of the patients coming through are in-center hemodialysis patients that have either an AV fistula, an AV graft, or surgical creations, or dialysis catheters, which are bridges until they get their surgical access,” Uttamchandani said. “The main procedures right now are being done in the center to ensure that those surgical accesses stay viable and healthy so that patients don’t get hospitalized.”