'Robotics is a great thing' but bundled payments will 'be a journey,' says AdventHealth spine director

Alan Condon -   Print  |

Nadia Fakira, MA, RN, is director of spine services at AdventHealth Neuroscience Institute at AdventHealth Orlando (Fla.), which performs more than 1,500 spine surgeries per year.

After more than 19 years of experience in specialized neurosurgical care, Ms. Fakira has extensive expertise in minimally invasive spine innovations, where robotic surgery is of particular interest.

"I think robotics is a great thing, but I truly believe it's the hospital protocols that help enhance the robots," said Ms. Fakira, who previously served on the neuroscience teams at UNC Hospital in Chapel Hill, N.C., and Duke University Medical Center in Durham, N.C. 

Robotic spine surgery continues to develop

"For us, you're up three hours after extubation no matter what the surgery is — whether it's robotic, navigated, or traditional fluoroscopic guided minimally invasive degenerative spine surgery, our patients have a successful outcome. As long as the disease process in their spine warrants them to be able to undergo minimally invasive spine surgery, they do great. They're ambulating the day of surgery and some do so well we can discharge one or two days after surgery."

After a recent hospital acquisition — AdventHealth Heart of Florida — the health system now features a variety of robotic and neuro navigation systems, including the Mazor X Stealth Edition, the Mazor SpineAssist, the ExcelsiusGPS and the 7D Surgical System.

The advantages of robotic and navigation assisted minimally invasive spine surgery have been well-demonstrated in the literature and recent studies: improved surgical accuracy, smaller incisions, shorter hospital stays, decreased complication rates and less radiation exposure.

However, with such high costs of these robotic systems — the ExcelsiusGPS and Mazor X costing about $1.5 million and $850,000 respectively — how can they produce value as the industry searches for more cost-effective options and value-based care in spine?

One such method is bundled payment programs, which AdventHealth is beginning to explore. Bundled payments have achieved some success in total joint replacements but the wide variation in spine procedures may hinder bundled payment programs finding the same success in spine. 

Can bundled payments achieve success in spine?

"For spinal surgery, it's going to be a journey," Ms. Fakira said. "I don't think it's as cut and dry as a hip or a knee. I think it's going to develop down the line, because we can now look at costs and quality. Nonetheless, I'm hopeful that down the line bundled payments are going to be helpful on the patient side of things and for hospitals from a cost perspective. This may require having more standardization of spinal care, which will need to be agreed upon by all stakeholders."

"Our surgeons have been practicing for a long time and over the years as we onboard newer physicians there is variation in surgeon technique. Our newer physicians are introduced to new technologies and minimally invasive techniques during their training and show a very innovative thought process to patient pathways and plan of care."

As technology advances and is reflected in the training of residency and fellowship programs, it's natural that a generational divide is manifested between the old guard and the up-and-comers. 

Spine care is developing rapidly, with newer neurosurgeons leaning toward conservative and minimally invasive treatments, opting for surgery as a final option after exploring nonsurgical treatments first.

"Evaluating the patient as a whole by looking at their quality of life, comorbidity, etc. will become even more important as our population ages. This will likely further drive degenerative spine surgery toward the minimally invasive route."

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