Alok D. Sharan, M.D., performs spinal fusions while his patients are awake, a procedure that has evolved in pursuit of a safer and better patient experience. It’s that exact word—experience—that the spine surgeon and Co-Director of Westmed Medical Group urges his colleagues and industry to consider in their daily work.
“Healthcare suffers tremendously from bad experiences,” Dr. Sharan says. “We can obviously just do the spine surgery, but I don’t think just doing the spine surgery is enough these days. For us to progress in this value-based movement, we need to think about the experience.”
Dr. Sharan’s own experience in mentoring a Ph.D. student and reading their study findings led him to contemplate patient experience more deeply, and act on performing spine surgeries on awake patients.
The research that inspired him found that patients age 65 or older who underwent general anesthesia for hip and knee replacement were more likely to develop delirium—sometimes days after surgery—when compared to spinal anesthesia. The results alarmed Dr. Sharan. He was sending his minimally invasive surgery patients home the same day as their procedure. Once home, what if these patients suffered delirium complications? The study results inspired him to perform laminectomies under spinal anesthesia, keeping patients awake. Nearly two years ago, he started to perform one-level lumbar fusions under spinal anesthesia. When we spoke in mid-December, he had performed 72 awake one-level lumbar fusions in total.
During the 60- to 90-minute procedure, a patient can move her upper body to remain comfortable, listen to music or even take a Benadryl to nap. To combat pain, Exparel is administered as a blocker and the patient is sent home with one week’s worth of narcotics.
Dr. Sharan has found that these patients are up and walking more quickly; their pain is controlled; they are discharged more rapidly and they have less delirium and anxiety. “We believe that we’ve completely transformed the experience of spinal fusion surgery and the overall outcomes because we’re able to do the procedure in a very benign fashion without much pain,” Dr. Sharan says.
A validation of Dr. Sharan’s awake method is that he was sought out to moderate a panel and speak on the topic during “Symposium: Outpatient Spine Surgery: The Next Frontier” at the NASS Annual Meeting in 2018.
Dr. Sharan has published a paper showing that awake laminectomies yielded a 10% cost savings vs. those performed under general anesthesia. He plans to publish a second study focused on cost savings for awake lumbar fusion. He believes that cost savings will be higher—around 20%—even excluding length of stay. Dr. Sharan has accomplished these savings by changing various factors under his control except for his surgical technique, which is often sacred to a surgeon. Dr. Sharan urges others to consider the same method when innovating. Speaking generally, are there ways to innovate before, after or around your main process or action? Speaking specifically, Dr. Sharan offers device companies these three questions to start with in an approach to product development.
- How are you making the procedure safer?
“Whenever I evaluate technology, I’m looking at it from a six-month point of view up to a six-year point of view. I see a lot of people getting older who are going to need more spine surgery. I would say that we need to look at tools that make procedures safer.”
As an example, Dr. Sharan points to DePuy Synthes’ SENTIO MMG, a digital platform designed to assess nerve status and identify and avoid peripheral nerves during surgery.
- How are you impacting episode of care?
For instance, Dr. Sharan uses Exparel, which requires an increase in surgical cost. But over the 90-day period, the cost is lower because patients are discharged faster. Surgeons seek solutions that lower the overall cost of the episode of care.
- How are you impacting the procedural experience?
Dr. Sharan admits that experience is hard to measure; he hasn’t determined a fool-proof method. But in today’s consumer-oriented era, companies like Amazon and Apple are setting high expectations for experience. Even though healthcare isn’t primed to capitalize on some of these expectations, it doesn’t mean that patients don’t expect it.
One example that Dr. Sharan provides is that his awake laminectomy patients have returned with adjacent-level breakdowns. He’ll suggest an injection, to which the patient will respond, if I’m just going to eventually have surgery, let’s skip the injection and go straight to the surgery. It’s an indication to Dr. Sharan that the first awake procedure experience wasn’t a big deal.
As more emphasis is placed upon episode of care, outpatient surgeries and the ambulatory surgical center (ASC) setting, device companies will be forced to consider how they’re impacting both the surgeon and patient experience to make procedures safer and better. Dr. Sharan serves as an example of how to find ideas and execute on change.
As for next steps with awake spinal fusion, Dr. Sharan would like to see greater adoption. His goal is to create proper selection criteria to determine which patients are prime candidates to go home the same day, and he is working on a suite of services and programs in order to move these procedures to the ASC setting.
Carolyn LaWell is ORTHOWORLD’s Chief Content Officer. She can be reached by email.