The procedures are becoming more viable in an outpatient setting, but only if the right patients and resources are involved.
This article first appeared in the September 2016 issue of HealthLeaders magazine.
Theodore Stringer, MD, a surgeon with Colorado Springs Orthopaedic Group, a board-certified orthopedic physician practice with subspecialty care offerings such as sports medicine, spine, and trauma, is laying the groundwork to begin offering outpatient joint replacement surgery. He expects payers to mount pressure to shorten hospital lengths of stay, but says of outpatient joint replacement, "I didn't want to be the first person [to do outpatient joint replacement surgeries], but I also don't want to be the last."
Stringer has studied the logistics of starting this venture, met with peers across the country who already provide these services, and surveyed interest from his own team, and realized that missing any key ingredient in the setup of offering outpatient joint replacement surgery could result in poor patient outcomes.
For outpatient joint replacement surgeries to be successful, the facility must have anesthesiologists skilled at regional blocking anesthesia, a 24-hour medical team must be in place for patient follow-ups and emergencies, and most important, the practice must be focused on patient selection and preoperative education and preparation.
"Outpatient joint replacement is not an option for a majority of patients, so we are preparing and trying to find the right patients," Stringer says.
The concept of outpatient joint surgery, which primarily includes total hip replacement, total knee replacement, and partial knee replacement, is not yet palatable to many surgeons. In fact, of the four arthroplasty specialists in CSOG's 18-person practice, only Stringer himself is currently on board and only wants to perform total knee replacements to start.
Scott Bergman, MBA, board member of the New Jersey Association of Ambulatory Surgery Centers and administrator at Cherry Hill, New Jersey–based Millennium Surgical Center, an advanced outpatient surgical center focusing on orthopedics, spine, pain management, and podiatry, says outpatient total knee replacements, which his multispecialty surgery center has been doing since 2014, are "profitable procedures, so you'd like to do more."
"In speaking to insurance carriers, they like outpatient joint replacement surgeries as well," he says. But like Stringer, he says candidate selection and preop screening dictate success.
Millennium Surgical Center has only performed 20 outpatient total knee replacements in the past two years due to the limited pool of patients who meet the team's stringent criteria.
"They tend to be younger and healthier patients who don't want to spend three or four days in a hospital, and are motivated to recover," Bergman says.
Doing total knee replacements outpatient at an ambulatory center, he says, lowers the risk of infection compared to doing so in hospitals. "We don't have sick patients here, so you don't have the risk of comingling. Also, we only do outpatient orthopedic procedures, so the patient isn't exposed to the risk that comes with following 'dirty' colonoscopies or other gastrointestinal procedures," he says.
Millennium has spent time and money to improve the knee replacement surgery program. But several technological advances have made the procedure minimally invasive. Surgeons use custom knee implants, created from CT scan images, to ensure a proper fit. "This cuts down on operating time and recovery time," Bergman says.
Patients are transferred to a private rehabilitation facility up to 23 hours after surgery. Surgeons have worked closely with the facility to create best practices for recovery. "There they get physical therapy two to three times a day to get the knee moving," he says.
Keith Reinhardt, MD, orthopedic surgeon at Northwell Health's Southside Hospital, a 341-bed tertiary facility in Bay Shore, New York, that specializes in multidisciplinary orthopedic care, says he is the only surgeon of three in his group doing outpatient joint replacement.
Reinhardt operates two days a week, performing three to six surgeries each day. Of those, one or two are outpatient and can be total knee replacements, partial knee replacements, or anterior total hip replacements. Unlike Millennium, Southside sends outpatient joint replacement patients home if they meet all discharge criteria.
"I've always been a big proponent of recovering at home. Recovery is better and [patients] have lower complication rates because they are forced to do more. They are up and around more, which means there is less risk for deep vein thrombosis," Reinhardt says. "Home is the right discharge place."
To ensure a smooth experience for the patient, Reinhardt held interdisciplinary meetings to explain to all staff interacting with patients the importance of a positive outlook regarding the outpatient surgery. "From the moment [patients] walk in the door to the minute they go home, they have to know they are going to do great."
He is also heavily involved in the patient selection process, working closely with a nurse practitioner and social worker to ensure the patient is fully prepped for surgery, postop, and discharge through a full home environment and social screen.
The nurse practitioner conducts a preop visit with the patient to learn of comorbities, medications, and other red flags. "If there is anything significant, we have them seen by a medical doctor after surgery and given medical clearance for discharge," he says. A social worker also contacts the patient to set up home physical therapy and a home visiting nurse as well as a walker and other equipment. "By the time the [surgery] day comes, the patient is aware and ready," Reinhardt says.
The power of anesthesia
Elie Joseph Chidiac, MD, chief of regional anesthesia section and residency program director at Detroit Medical Center/Wayne State University in Detroit, says outpatient joint replacement surgery is succeeding because modified surgery techniques cause less tissue damage, inflammation, and pain, and anesthesiologists, using a multimodal approach, are able to better control side effects such as nausea and pain. Detroit Medical Center does both outpatient and inpatient knee replacements, but only patients with partial knee replacements are allowed to go home on the day of surgery.
In addition to preoperative medications to control nausea, allergies, and pain for patients, the team uses an adductor canal catheter with a diluted local anesthetic to block the nerve. The patient is able to go home with the catheter and remove it after three days, Chidiac says. The anesthesiologist who placed the catheter is required to not only follow up with the patient but to supply a phone number to the patient for emergencies.
Southside's Reinhardt says that while he considers a catheter an effective mode for anesthesia, he worries whether the patient would be able to keep it clean. Therefore, his team uses a periarticular injection administered during surgery that lasts for one to two days.
Outpatient surgeries cause more work for anesthesiologists because they require advanced nerve blocking skills, Chidiac says. As a result, anesthesiologists tend to be more involved with patient screening, asking deeper questions about a patient's general health. "We also have to have a backup plan in case the patient reports severe pain in postop," he says.
The benefit, though, is in most cases you have an alert and pain-free patient postop, Chidiac says. "You have higher patient satisfaction for less cost," he says.
A big operation
Although surgeons report satisfaction among the limited outpatient surgeries they are performing, some worry that there could be a false sense of security.
"This is still major surgery—I don't care how you slice it," says William J. Dowling, MD, chair of orthopedics services at Morristown Medical Center in New Jersey. "While we've become much more sophisticated and facile with surgical technique, this is still significantly invasive," he says.
Of the 2,200 joint replacement surgeries orthopedics services performs each year, Dowling says 2% percent (or 44 surgeries) are outpatient—primarily partial knee replacements.
Like Reinhardt, he says home for recovery is the right place for carefully screened patients and has found the risk of being readmitted to the hospital from home lower than from a rehabilitation or skilled nursing facility. "When you go home, you tend to fend for yourself and get back to your life as opposed to being a patient," Dowling says.
But, he warns, that doesn't mean patients can't have the same complications as their inpatient counterparts such as heart attack, stroke, blood loss, infections, and blood clots. "The reason you stay in the hospital is not only to control pain discomfort, but also to monitor excessive anemia and lightheadedness that can come with blood loss," he says. Also physicians must ensure that patients can walk and be able to function safely without fear of falling or injury. There must be room for judgment calls in postop, including hospital admittance, Reinhardt says.
Exiting the outpatient waters
William Long, MD, medical director of the Orthopaedic Computer Surgery Institute at Good Samaritan Hospital in Los Angeles, has a cautionary tale about the potential downsides of outpatient joint replacement surgery.
Long's early experience with outpatient hip replacement taught him that it is not an appropriate option for many patients. He learned that outpatient hip replacement requires special education for the patient and the family, and a special support team of providers to take phone calls around the clock.
"You must be better at figuring out who the patient is before you operate on them than for inpatient," Long says. "It's also your responsibility to know the family and know whether this is the right decision for them."
He says this requires longer office visits with the surgeon before surgery, because it can take up to an hour to explain the procedure and answer all the patient's questions. "Following surgery, an inpatient can push a button to summon a nurse for assistance," he adds. "Outpatients also require access to a knowledgeable provider to ask questions, such as, 'What do I do about uncontrolled pain? When is blood on the dressing an emergency? What do I do with persistent nausea?' "
Patients must feel comfortable enough with the outpatient procedure and what to expect after the surgery that they don't rush to the ER or ask to be readmitted to the hospital.
Surgeons are required to have a 24-hour number manned by skilled nurses or the surgeon. After the RN assigned to his 24-hour line left the practice, Long began taking the calls and was soon exhausted. "I had to take personal responsibility for everyone that went home that night," he says.
Long realized he did not have the resources to staff his practice adequately to handle the demands of outpatient joint replacement patients. Most surgeons who perform joint replacement do not have the resources to pay for an on-call team, and hospitals are not required to provide those resources, he says. "Outpatient surgeons save hospitals money because the hospitals don't have to provide care for the patient after the operation; there is no requirement that the hospital provide care for the patient at home. That responsibility could fall squarely on the surgeon and his personal resources. Surgeons can't be expected to operate all day and take calls all night."
He worries that if payers start pressuring surgeons toward outpatient, they won't consider these requirements. "Yes, outpatient surgery can be a great thing if the patient has adequate personal resources, but it could also be an evil thing if it is just forced upon the public as the new standard of care," he says.
Dowling agrees. He says he understands the lure of outpatient procedures for surgeons and payers. "Almost every year, there's a shift of 10% to an outpatient setting, and I expect this to continue, including shoulder replacements," he says. "Compensation reimbursement in ambulatory settings is decent, and that's attractive to surgeons if they want to assume risk," he says. "But you have to set yourself up so other contingencies are available."
He adds that if doctors were comfortable with outpatient joint replacement procedures, you'd see a greater increase in those doing them. "We're not seeing that. Instead it's slow and incremental," he says.