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Chapter 51

### INTRODUCTION

An increasing number of patients are undergoing surgical procedures in hospital outpatient departments (HOPDs) or ambulatory surgery centers (ASCs).1 Outpatient surgical procedures have become more complex, and patients are presenting for surgery with a greater number of comorbid conditions than in the past.2 Regional anesthesia (RA) and peripheral nerve blocks (PNBs) can help meet the goals of caring for these patients in the outpatient setting.

In 1976, there were 67 Medicare-certified ASCs in the United States, and in 2011, there were 5,344.3 In 1982, 30 ambulatory surgical procedures were covered by Medicare; today there are hundreds.4 In an analysis of National Survey of Ambulatory Surgery (NSAS) data, Tighe et al. found that 15% of an estimated 4 million orthopedic outpatient cases implemented a “regional block” as part of the anesthetic used.6,7 Over 580,000 PNBs were performed in HOPDs or ASCs in 2006.5

From 2006 to 2010, outpatient services per Medicare enrollee increased by 5.7% annually. In 2011, the rate increased by 1.9%, accounting for $3.4 billion in charges, a 2.2% increase from 2010.3,4 Currently, about 57 million outpatient procedures (surgical and nonsurgical) are performed in the United States at a cost of$3.2 billion.4,8 In 2014, over 3 million of these cases are estimated to be orthopedic procedures.5 At some institutions, including the authors’, most PNBs are performed for orthopedic cases.9 Based on NSAS data from 1996 through 2006, arthroscopic knee procedures in the U.S. increased by 49%.10 As minimally invasive surgery becomes available for surgeries that require an inpatient stay due to the severity of postoperative pain, RA can allow for safe same-day discharge.11 A study by Koenig and Gu indicated that the growth of ASCs may reduce Medicare spending due to lower reimbursements relative to number of hospitals.12 There is preliminary evidence that outcomes at ASCs are better than those at in-hospital settings for similar otolaryngologic surgical cases.13 Future research in this area needs to be completed for other services.

With the growth in both complex outpatient surgeries and ASCs, there is a need for more anesthesiologists with specific training in the use of acute pain medicine with integrated RA and PNB techniques. With the use of these techniques, the first priority should be on safety, the second on reducing patient pain and minimizing opioid and general anesthesia (GA) side effects, the third on economics, and the fourth on efficiency.14,15

#### Outpatient Surgery Stakeholders

Patients, providers, payers, and “internal customers,” including anesthesiologists, nurses, and support staff,16 may have differing views on the value on the various outpatient operational and clinical outcomes. In healthcare, value is defined as patient outcome per costs used to achieve those outcomes.17,18 For payers, value consists of providing a service with good outcome at ...

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