Summary

Ambulatory surgery center utilization (ASC) for hip arthroscopy increased from 2013 to 2017. ASCs have lower odds of being in-network than outpatient hospitals, which may constrain further expansion.

Abstract

Introduction

Hip arthroscopy (HA) is a minimally invasive procedure that has seen significant growth in its utilization across the U.S. when treating patients with symptomatic femoroacetabular impingement (FAI). Prior studies comparing outpatient hospitals (OHs) versus ambulatory surgery centers (ASCs) found no difference in rates of postoperative complications between surgical sites for HA patients; however, utilization of ASCs for HA remains low. This study aims to investigate the predictors of ASC versus OH utilization for HA to better understand opportunities and barriers to moving HA patients to the ASC setting.

Methods

This retrospective cohort study utilized the 2013-2017 IBM MarketScan Commercial Claims Encounter database to evaluate patients who underwent a HA at an ASC or OH in the U.S.. Current Procedural Terminology (CPT) codes were utilized to identify patients who underwent debridement-only (29860, 29861, 29862, 29863), FAI surgery (29914, 29915), or hip labral repair only (29916). A multivariable logistic regression was utilized to determine the odds ratio (OR) of ASC utilization when considering the patient’s gender, age, geographical region of the U.S., insurance plan type, calendar year, Deyo-Charlson Comorbidity Index (DCCI) score, obesity/smoking/osteoarthritis status, surgeon/facility network status, peripheral nerve block (PNB) utilization, and procedure type. Statistical significance was set at p<0.05, and 95% Confidence Intervals (95% CI) are reported.

Results

A total of 20,335 HA procedures were identified; 6,077 performed at ASCs and 14,258 at OHs. ASC utilization increased over the study period (OR:1.09; 95% CI:1.07-1.12; p<0.001). Surgeons were significantly more likely to be in-network when the procedure was performed at an ASC (OR:1.63; 95% CI: 1.35-1.96; p<0.001); however, ASC facilities themselves were less likely to be in-network (OR:0.59; 95% CI:0.49-0.70; p<0.001). Factors that increased odds of ASC utilization included geographical location, namely Southern U.S., patient age 45 to 54 years, debridement-only procedures, and High Deductible Health Plan (HDHP) and Consumer Driven Health Plan (CDHP) coverage (all p<0.05). High DCCI scores, obesity, smoking history, osteoarthritis diagnosis, Health Maintenance Organization (HMO), and Point of Service (POS) plans decreased ASC utilization (all p<0.05).

Conclusion

The increasing ASC utilization for HA over the study period is consistent with broader trends observed among orthopedic procedures. Obesity, smoking status, and higher comorbidity burden had lower odds of ASC utilization, in keeping with strict ASC screening criteria for patients. Older patients had higher odds of ASC utilization, likely due to the observed increased odds of debridement-only surgery being performed at ASCs due to shorter operative times. Surgeons may also have a hesitancy to perform longer FAI procedures in the ASC setting, despite evidence demonstrating its safety. Overall, this study demonstrated significant opportunities for the expansion of ASC utilization for HA procedures among patients; however, the facility out-of-network status of many ASCs may present a barrier to their increased utilization.