Many spine surgeons and patients have benefitted from outpatient migration when it comes to costs and outcomes, but the option for inpatient stays will always remain.

Three spine surgeons discuss how their hospitals are facing shifting needs.

Note: Responses were lightly edited.

Question: Inpatient spine care will still be needed for extra complex spine cases and for patients with high co-morbidities. How is your hospital’s spine program evolving to meet those evolving needs?

Philip Louie, MD. Virginia Mason Franciscan Health, (Seattle): To meet the growing demands of complex inpatient spine care, we have built a data-driven, multidisciplinary program that prioritizes safety, efficiency and value across the entire surgical episode.

1) Multidisciplinary Preoperative Case Conferences: All complex cases undergo structured case review with surgeons, anesthesia, hospital medicine, psychology, and PM&R to align care plans and preempt avoidable risks.

2) Psychological and Behavioral Health Screening: Every patient is evaluated for psychological distress and expectation management to improve readiness, reduce regret, and support long-term recovery.

3) Time-Driven Activity-Based Costing (TDABC): The team applied TDABC to quantify the cost and value of their spine conferences, demonstrating approximately $400,000 in annual savings through reduced complications.

4) Shift from Post-Admission to Pre-Admission Delays: Through early optimization, most delays now occur before hospitalization, minimizing costly OR disruptions and improving throughput efficiency.

5) Lean Methodology and Standardized Care Pathways: Inspired by the Toyota Production System, protocols streamline care delivery, reduce variation, and improve quality across the entire spine episode.

6) Patient Education and Group Interventions: Chronic pain patients are offered group-based behavioral health education to improve coping skills, social connection, and engagement in their care.

Daniel Sciubba, MD. Northwell Health (New York City): Our new Northwell Spine Institute has been modeled to directly address the evolving landscape of spine care, ensuring we cater to the full spectrum of patient needs – from the simplest to the most complex. Recognizing that inpatient spine care remains indispensable for highly intricate cases and patients with significant co-morbidities, our institute is designed to manage the entire portfolio of spine issues. This comprehensive approach spans the full continuum of care, beginning with conservative measures like outpatient activity modification and physical therapy, progressing through advanced pain management interventions, and extending to less invasive outpatient surgical procedures when appropriate. This tiered system ensures that patients receive the most suitable and least disruptive care initially, while retaining the capability for more intensive interventions.

A cornerstone of the Northwell Spine Institute’s strategic design is the robust support provided by our network of flagship hospitals throughout the New York City Metro area. These institutions serve as essential backstops and foundations, guaranteeing that comprehensive, inpatient spine care is readily available whenever outpatient solutions are not feasible or sufficient. This integrated setup is particularly advantageous in today’s healthcare environment; while we adeptly leverage cutting-edge technologies to perform increasingly less invasive procedures on a growing number of patients in the outpatient setting, we are simultaneously treating an aging, more frail population. These latter patients, often presenting with multiple co-morbidities or requiring extensive reconstructive surgeries, frequently necessitate the comprehensive support of a multidisciplinary team within the inpatient hospital setting, a level of care our flagship facilities are uniquely equipped to provide.

Programmatically and financially, this tiered model allows us to respond effectively and responsibly to the diverse needs of our patients and their families. It ensures that care is precisely tailored to the “best fit” for each situation. Healthy patients requiring minor procedures are not unnecessarily subjected to the costs and inconvenience of inpatient options, benefiting instead from efficient and appropriate outpatient care. Conversely, older, more frail patients, or those undergoing complex reconstructions, are seamlessly transitioned to receive the extensive, comprehensive, and multidisciplinary inpatient support that their conditions demand, optimizing outcomes while ensuring fiscal responsibility across the entire spectrum of spine care.

Christian Zimmerman, MD. St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): Most larger health systems (locally) have vested, well-established mechanisms to accommodate the more complex surgical and patient populations. From insurance submission for surgical procedures to the accompanying/expected length of stay (LOS), most of these prospective complex procedures are well strategized and completed with superior outcomes. Depending on the ASA Categorization to the unexpected co-morbid singultus, there is both a Neuro ICU and step-down units with specialized nursing, intensivist oversight and designated resource management in place at all hours to manage these complicated patients. As healthcare policy changed, reimbursements etiolated and shifts in complex, underserved patients were forced upon larger health systems the evolution, growth and maintenance of this program paralleled the need. This is a well oiled, well established program, whereby all staff from pre-operative services to post operative management including nursing and anesthesia are well prepared and comfortable in patient directives and care.

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