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Although it can be difficult to turn a profit on outpatient laparoscopic Nissen fundoplication-or even turn it into a break-even proposition-those who offer it agree that it is a procedure worth fighting for. The procedure, which involves wrapping the fundus around the lower esophagus to prevent stomach acids from refluxing into the esophagus, is clinically successful in properly screened patients, can help sharpen the healthcare team's skills, improves overall patient care, and is significantly less costly than the same inpatient procedure. Perhaps even more exciting, says Eric J. DeMaria, MD, FACS, Director of the Center for Minimally Invasive Surgery with the Medical College of Virginia Hospitals, is the fact that advanced laparoscopic procedures like fundoplication are redefining the boundaries of outpatient surgery. "I don't think we yet know the limitations of outpatient surgery," he says. "Advances in laparoscopy are redefining these limits."
Clinical Success
The healthcare team at the Jefferson Memorial Surgery Center in Festus, Mo., began offering outpatient laparoscopic fundoplication early last year and have since performed six cases without a complication or problem. In fact, most of the patients didn't stay the full 23 hours. Gregg Ginsburg, MD, general surgeon with the center, attributes this early success to two primary factors:
To further ensure outpatient success, Dr. DeMaria notes that the surgeon must be experienced, 23-hour care must be available, and the facility must be prepared to handle the rare but not insignificant risk of complication (e.g., the facility is hospital-based or has a transfer agreement in place).
Skill Booster
Both Dr. DeMaria and the healthcare team at Jefferson say this procedure has challenged their outpatient staffs, and in both cases the staffers have risen to the challenge. The result, they agree, is increased confidence and improved surgical/anesthesia skills.
The outpatient anesthesia team at the Medical College of Virginia Hospitals has very nearly perfected techniques to ensure patient comfort, according to Dr. DeMaria, and this contributes greatly to outpatient success. Patients receive pre-emptive Zofran to minimize postoperative nausea and vomiting (PONV). During surgery, all wounds are infiltrated with an anesthetic solution of 1% Xylocaine (for immediate relief) plus bupivacaine (for long-acting relief). Immediately postop, patients receive IV fentanyl and morphine as well as a dose of oral narcotic to maintain pain control during the transition from the PACU to the hospital bed. After surgery, patients receive Phergan or Compazine suppositories to further minimize PONV.
Dr. DeMaria also says he has learned to minimize postoperative pain by taking the following precautions during surgery:
Improved Care
At the Medical College of Virginia Hospitals, approximately 75 percent of laparoscopic fundoplication patients stay just 23 hours or less. (The remaining patients are typically admitted because they need more time to successfully convert to oral pain medications or they cannot yet tolerate a liquid diet). According to Dr. DeMaria, these patients gladly accept the idea of going home as long as the team can make them comfortable. In fact, he says, patients who are prepared to go home tend to have a much more positive outlook on their recovery.
There is also less likelihood that patients will be exposed to infection in the outpatient setting. "Last year, our infection rate was 0.08 percent for all procedures for the entire year," notes Barbara Baker, RN, administrator with the Jefferson Memorial Surgery Center. "Importantly, patient satisfaction is also high among our patients, thanks to the personalized care and our well-appointed overnight care facility."
Reduced Cost
In a study of 38 laparoscopic fundoplication patients by Dr. DeMaria and his colleagues, the outpatient approach reduced the hospital's per-case facility costs by an average of 36 percent-from $7,169 for the average inpatient procedure to $4,588 for the average outpatient procedure. Nonetheless, in the current climate, it can be difficult to turn a profit on this procedure. The average APC hospital outpatient Medicare reimbursement for laparoscopic fundoplication is just $2,483, and the inpatient reimbursement is approximately $5,000-both of which fall well below these average case costs.
The Jefferson healthcare team faces a similar financial scenario, even though their costs are relatively low because they borrow one of the primary instruments-the harmonic scalpel, a $25,000 investment-from the local hospital. Medicare does not reimburse for this procedure when performed in a freestanding ASC, and the facility reimbursements Jefferson has been able to obtain from other insurers vary so drastically that the center cannot ensure financial feasibility. Jefferson's average facility reimbursement has been just $1,860, which barely covers actual costs, and the reimbursements have ranged from $624 to $5,034 per case.
Facilities that offer this outpatient procedure agree that there appears to be a lack of understanding among many insurers of the advanced nature of this procedure and the suitability of performing it in the outpatient setting. For an outpatient procedure, laparoscopic fundoplication takes substantial operative time and postoperative care, and supply costs are fairly significant.
At Jefferson, the following items comprise the bulk of the per-procedure supply costs:
Expanded Horizons
Healthcare teams who offer this outpatient procedure are convinced that it belongs in the outpatient setting and say they will fight to renegotiate improved insurance contracts. For them, laparoscopic fundoplication marks the beginning of a new future for outpatient surgery. Besides paving the way for bigger and better laparoscopic procedures in the future, fundoplication has helped some outpatient facilities expand their horizons in other directions as well. "The experience has increased the confidence of our staff and allowed us to see that we can take on bigger procedures with confidence," says Ms. Baker. "We're working to bring in more ACLs and hope to take on vaginal hysterectomies and possibly mastectomies."
Clinical Success
The healthcare team at the Jefferson Memorial Surgery Center in Festus, Mo., began offering outpatient laparoscopic fundoplication early last year and have since performed six cases without a complication or problem. In fact, most of the patients didn't stay the full 23 hours. Gregg Ginsburg, MD, general surgeon with the center, attributes this early success to two primary factors:
- Careful patient selection. Outpatient candidates include relatively young, otherwise healthy patients (ASA classes I and II). Laparoscopic surgeons generally agree that outpatient facilities cannot safely offer this procedure to patients with prior upper abdominal surgeries (which increases the potential for open conversion) or to patients with comorbidities such as cardiac disease or obesity. Dr. DeMaria has performed the outpatient procedure on patients with diabetes, however, provided the condition is well-controlled.
- Personalized care. All six patients at the Jefferson Memorial Surgery Center have expressed a high level of satisfaction. Dr. Ginsburg attributes this to the high level of personal care patients receive at the 23-hour care facility. When performed well, laparoscopic fundoplication is also inherently successful. In the medical literature, approximately 90 percent of patients overall report a good result after laparoscopic Nissen fundoplication.
To further ensure outpatient success, Dr. DeMaria notes that the surgeon must be experienced, 23-hour care must be available, and the facility must be prepared to handle the rare but not insignificant risk of complication (e.g., the facility is hospital-based or has a transfer agreement in place).
Skill Booster
Both Dr. DeMaria and the healthcare team at Jefferson say this procedure has challenged their outpatient staffs, and in both cases the staffers have risen to the challenge. The result, they agree, is increased confidence and improved surgical/anesthesia skills.
The outpatient anesthesia team at the Medical College of Virginia Hospitals has very nearly perfected techniques to ensure patient comfort, according to Dr. DeMaria, and this contributes greatly to outpatient success. Patients receive pre-emptive Zofran to minimize postoperative nausea and vomiting (PONV). During surgery, all wounds are infiltrated with an anesthetic solution of 1% Xylocaine (for immediate relief) plus bupivacaine (for long-acting relief). Immediately postop, patients receive IV fentanyl and morphine as well as a dose of oral narcotic to maintain pain control during the transition from the PACU to the hospital bed. After surgery, patients receive Phergan or Compazine suppositories to further minimize PONV.
Dr. DeMaria also says he has learned to minimize postoperative pain by taking the following precautions during surgery:
- Careful trocar placement. Trocars placed too close to the costal margin on the patient's left side tend to cause intercostal nerve irritation and postoperative discomfort.
- Downsized laparoscopic incisions. Dr. DeMaria usually performs these procedures with 5-mm trocars and just one 10-mm trocar for the Endostitch device. "In my experience, this decreases pain significantly," he says.
Improved Care
At the Medical College of Virginia Hospitals, approximately 75 percent of laparoscopic fundoplication patients stay just 23 hours or less. (The remaining patients are typically admitted because they need more time to successfully convert to oral pain medications or they cannot yet tolerate a liquid diet). According to Dr. DeMaria, these patients gladly accept the idea of going home as long as the team can make them comfortable. In fact, he says, patients who are prepared to go home tend to have a much more positive outlook on their recovery.
There is also less likelihood that patients will be exposed to infection in the outpatient setting. "Last year, our infection rate was 0.08 percent for all procedures for the entire year," notes Barbara Baker, RN, administrator with the Jefferson Memorial Surgery Center. "Importantly, patient satisfaction is also high among our patients, thanks to the personalized care and our well-appointed overnight care facility."
Reduced Cost
In a study of 38 laparoscopic fundoplication patients by Dr. DeMaria and his colleagues, the outpatient approach reduced the hospital's per-case facility costs by an average of 36 percent-from $7,169 for the average inpatient procedure to $4,588 for the average outpatient procedure. Nonetheless, in the current climate, it can be difficult to turn a profit on this procedure. The average APC hospital outpatient Medicare reimbursement for laparoscopic fundoplication is just $2,483, and the inpatient reimbursement is approximately $5,000-both of which fall well below these average case costs.
The Jefferson healthcare team faces a similar financial scenario, even though their costs are relatively low because they borrow one of the primary instruments-the harmonic scalpel, a $25,000 investment-from the local hospital. Medicare does not reimburse for this procedure when performed in a freestanding ASC, and the facility reimbursements Jefferson has been able to obtain from other insurers vary so drastically that the center cannot ensure financial feasibility. Jefferson's average facility reimbursement has been just $1,860, which barely covers actual costs, and the reimbursements have ranged from $624 to $5,034 per case.
Facilities that offer this outpatient procedure agree that there appears to be a lack of understanding among many insurers of the advanced nature of this procedure and the suitability of performing it in the outpatient setting. For an outpatient procedure, laparoscopic fundoplication takes substantial operative time and postoperative care, and supply costs are fairly significant.
- Operative time. At the Medical College of Virginia Hospitals, outpatient laparoscopic fundoplication takes approximately two hours (from patient preparation to extubation).
- Postoperative care. The procedure requires a one-to-one or two-to-one patient-to-nurse ratio during the postop period to monitor vital signs, ensure comfortable patient positioning, and maintain pain control.
- Supply costs. General surgeons agree that the harmonic scalpel and the Endostitch device are essential to performing the procedure safely and efficiently. The scalpel-which evaporates rather than burns tissue and fat away from the stomach using ultrasonic energy-minimizes thermal necrosis of surrounding tissues and can reduce postoperative pain and scarring. The Endostitch device allows the surgeon to sew the fundus around the lower esophagus and tie knots with a one-handed laparoscopic instrument.
At Jefferson, the following items comprise the bulk of the per-procedure supply costs:
- Harmonic scalpel disposables: $345.
- Endostitch disposables with reloads (for sewing the fundus around the lower esophagus): over $100.
- Disposable trocars: Approximately $109. (The reusable trocars the facility evaluated were too tough on the tissues and caused too much bleeding).
- Organ retractor: $120.
- Non-crushing Babcocks: $54/procedure ($540 each, reusable 10 times).
Expanded Horizons
Healthcare teams who offer this outpatient procedure are convinced that it belongs in the outpatient setting and say they will fight to renegotiate improved insurance contracts. For them, laparoscopic fundoplication marks the beginning of a new future for outpatient surgery. Besides paving the way for bigger and better laparoscopic procedures in the future, fundoplication has helped some outpatient facilities expand their horizons in other directions as well. "The experience has increased the confidence of our staff and allowed us to see that we can take on bigger procedures with confidence," says Ms. Baker. "We're working to bring in more ACLs and hope to take on vaginal hysterectomies and possibly mastectomies."
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