Jefferson Surgical Center at the Navy Yard Administrator Joseph DeMarco and surgeon Jess Lonner, MD, and Orthopaedic Associates of Wisconsin Chief Administrative Officer Mark Smith discuss why they created a robotic technology program at their ASCs and where they see the biggest opportunities for success in the future.
This article is sponsored by Blue Belt Technologies.
Q: Why did you decide to consider a robotics program at your ASC?
Mark Smith: We've been familiar with robotics in orthopedics since around 2009. Our surgeons have used them for a few different procedures since then and it became a natural evolution for our ASC. We are now looking to do more traditional inpatient procedures in the outpatient setting and since we were familiar with the technology we wanted to look for an opportunity to incorporate it into our ASC.
Joseph DeMarco: The robotics program was requested by one of our surgeons. The surgeon believes that partial knee replacement is the right format for the ASC and the robotic technology allows for the precision he needs in this type of procedure. Therefore, it was an initiative for Rothman Institute to be successful in the outpatient arena and robotics played a key role in that function.
Q: Dr. Lonner, why did you decide to incorporate robotics into your practice?
Dr. Jess Lonner: Robotic technology is now used in 15 percent of partial knee replacements in the United States. We have shown, in addition to other investigators that compared to conventional techniques the use of robotics can substantially improve the precision of bone preparation, prosthesis alignment and soft tissue balance in partial knee replacements, all of which improve outcomes and durability.
The enhanced precision and optimized outcomes have raised substantially the interest in robotics in partial knee replacement surgery, but until Navio became available, it just wasn't economically feasible for it to be used in ASCs since prior robotic systems cost upward of $1 million.
Q: Mr. Smith, why did you decide to purchase the Navio system?
MS: From a business standpoint, being able to perform those surgeries traditionally inpatient in the outpatient ASC will deliver volume to the ASC. It's much less expensive for the patient and payer because charges are less than in the hospital. Additionally, we think the Navio robotic technology gives patients a superior outcome. There is greater precision, minimal incision and shorter rehabilitation times.
Q: What benefits do you see over comparative technologies?
MS: First of all, there is no CT scan required. That already makes it a less expensive procedure because you don't have to include those images. There is also an ease of use our surgeons experience with this technology. Our surgeons are excited about that.
We were really fortunate because our guys have used the robotic technology for years, so there was a high degree of familiarization with it.
JD: The cost of the new technology is important. There aren't a lot of choices when it comes to robotics, especially systems that had what we were looking for in partial knee replacements. I think the real benefits are in the fact that as healthcare continues to change and the ASCs become more of a leader in the answers to healthcare costs, insurance companies will look for more opportunities to approve cases for the outpatient setting. Patients will also look to control costs, especially for higher acuity cases.
Q: How many partial knee replacements are performed in the United States today? Do you think that number will grow in the future?
JL: Estimates vary regarding the penetration of partial knee replacements in the United States, but a current conservative estimate is that approximately 10 percent of the knee replacements performed are partials. This is a relative underutilization of a procedure that may be appropriate for 30 percent to 40 percent of surgical candidates who have single compartment knee arthritis.
It is projected that the numbers of knee replacements will explode by more than 650 percent over the next 25 years. If we consider that between 1998 and 2005 the utilization of partial knee replacements increased at an average yearly rate of 32.5 percent compared to the total knees which increased by an average of 9.4 percent during the same interval, one can only imaging the future growth rate of partial knee replacements, particularly as we train more current and future generations of residents in the use of partial knee replacements.
This will create tremendous opportunity for ASCs, where growing numbers of partial knee replacements will continue to be performed.
Q: Will Medicare and other payers embrace partial knee replacements and robotic technology in the outpatient ASC?
JL: Relative costs to Medicare and other payers are less in the ASC than a general hospital, so they are welcoming in a big way this initiative. Medicare pays ASCs a percentage of what they pay general hospitals, but in our ASC analysis, the profits even with Medicare patients have made our program worthwhile. The profits with commercial payers are as good as the contracts you negotiate.
For our ASC, some contracts are better than others, but we are collecting our outcomes data and negotiating with commercial payers.
Q: How many procedures will you need to do in order to break even on the Navio investment?
MS: That will be contingent on the payer mix, but we estimate if we can do somewhere in the neighborhood of 35 to 40 total procedures we'll break even. We don't think that's a lot. We're going to be very selective in the patients we bring to the ASC, but we hope to see a return on investment within six months to a year.
Q: Dr. Lonner, you have performed a few of the partial knee replacements in the ASC with Navio. How did the transition go? Are you happy with the results?
JL: We performed an initial cadaveric study of 25 knees and determined that the precision of bone preparation using Navio was far better than what is achieved with conventional instruments. In a clinical study of the initial 70 cases performed with the Navio we found that the achieved alignment was within one degree of the preoperative plan in 92 percent of the cases.
Additionally, we have had no instances of inadvertent soft tissue complications. The technology has proven safe.
Finally in our feasibility study assessing our initial experience with 30 outpatient partial knee replacements in our ASC — some days having done five partials and an arthroscopic surgery or two — we found that all patients were successfully discharged home after spending a mean of three hours in the PACU. We have had no readmissions to nearby hospitals in this initial cohort.
Q: Based on your experience, what are your strategies for success with the Navio system in an ASC?
JL: "Buy in" from ASC administrators, nurses, anesthesiologists, technicians and other staff members are critical for successful implementation of an outpatient robotics program in your ASC. In ours, this was never in doubt. All critical personnel have more than embraced the program, risen to the occasion and enjoyed the challenge of training with Navio and doing cases in an ASC that until now focused on conventional outpatient procedures.
Staff and space have been allocated specifically for these robotic cases and requisite inventory. Each member of the team has taken pride in the care of these patients and relishes in knowing that they are doing something that has never been done in the greater Philadelphia area.
Q: Mr. DeMarco, from your perspective, how has the system fit into the surgery center?
JD: The biggest challenge has been that partial knee replacements include more equipment and trays than some of the other procedures at our ASC. That adds some extra work for our staff. Before bringing in the procedure, the staff have to attend an in-service day so they understand how the technology is used successfully.
There is a mindset for the surgery center that needs to be challenged with these more complex procedures. The operating room times are longer — about an hour — so staff must become aware of that.
Q: What needs to happen before ASCs can fully implement robotic programs?
JL: Specialized clinical pathways must be formalized and implemented to make the program work. Preoperative education and planning are keys to our success. Thorough counseling by a nurse and explicit handouts should review the details of the procedure and perioperative experience — from preop physical therapy to setting up postop PT in advance; preop and periop medications and prescriptions with detailed instructions regarding timing and dosages; ensuring support at home; providing prescription for cooling unit; details regarding dressing and wound care; timeliness regarding anticipated functional milestones.
All of these will help with the entire perioperative process and enhance patient understanding and comfort. Regional anesthesia, periarticular injections, fluid and nausea management and compassionate and competent perioperative nursing care and the other critical and achievable elements to a successful outpatient robotic partial knee replacement program.
Q: Do you think we will see an increase in ASCs adopting robotics?
JD: I do. I think we are all concerned about healthcare in general and surgery centers are an answer for a lot of the higher acuity cases as long as the patient fits the criteria for outpatient surgery. We are talking about high acuity cases, but treatment for healthy patients. A lot of our surgeons focus on sports medicine, and these athletes are injured, but otherwise in great shape.
Then patients can go home and we bring services to them. Depending on what part of the country you live in and the choices people have, ASCs can be a great option for the more complex cases.
MS: I certainly hope [we'll see an increase]. We see some real advantages in seeing those procedures in the outpatient setting. We are allowed to do Medicare partial knee replacements in ASC, which is what the robotic technology allows us to do. We see this as a natural evolution of the ASC and this technology allows us to provide patients with the latest equipment and best outcomes possible.
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