There are more than 250 ambulatory surgery centers (ASCs) across the U.S. where surgeons perform total joint replacements, and that number is expected to grow due to regulator updates and a focus on value-based care.
In 2020, CMS will pay for total knee replacements in ASCs for the first time, opening up the possibility for an entirely new patient population to undergo surgery at an ASC. The agency has also removed total hip replacement from the inpatient-only list, allowing surgeons to perform them in hospital outpatient departments. Total joint replacement patients who are good candidates for the outpatient setting are now able to seek care in ASCs, which provide a high-quality, low-cost option for orthopedic care. Additionally, as the healthcare system moves toward value-based care, the volume of outpatient total joints is expected to skyrocket, driving even more total joint traffic into the ASC.
According to Sg2, 15 percent of total joint replacements were performed outpatient in 2017, and that number is expected to reach 32 percent next year. By 2026, 51 percent of total joint replacements could be outpatient procedures, which is a huge opportunity for ASCs.
Surgeons across the country, including Alexander Sah, MD, of Sah Orthopaedic Associates in Fremont, California, and Donald Knapke, MD, of Michigan Orthopaedic Surgeons in Troy, have gotten a head start on outpatient joint replacement in ASCs and have perfected a method for performing these high-value procedures at their centers. The actual surgery is the same procedure surgeons perform in the inpatient setting, but they must be performed more efficiently and with enhanced comprehensive protocols, and ASC staff must give the patient the right tools for a successful recovery at home.
“Outpatient total joints is really building upon a successful inpatient program and doing those procedures in the hospital first, and then moving them to the surgery center,” Dr. Sah said.
“Surgeons need the right foundation for protocols in place for proper patient selection, education, anesthesia techniques, and discharge within 24 hours before moving cases into the ASC. Then, the real challenge is there is much less time that you have the patient in the facility to treat and educate them before discharge. You have to make sure everything is done right the first time and the patient has a consistent message about what to expect so they can recover well at home.”
This article outlines how Drs. Sah and Knapke transitioned total knee replacements to the ASC and refined their techniques to achieve better patient outcomes, lower narcotic use among patients, and success with bundled payments.
Consistent messaging and protocols
From the day patients decide to undergo an outpatient total knee replacement through scheduling the procedure, Dr. Knapke makes sure his colleagues and staff deliver a consistent message about outpatient expectations to the patient. During the month between scheduling surgery and the actual procedure, patients attend a class or meeting at the surgical center, which also allows them to become familiar with the facility before surgery. The presurgical protocol also includes:
• Pain management and medications
• Meeting physical therapists and nurses that will care for
them during the postoperative period
• Beginning an exercise protocol
When Dr. Sah first proposed performing outpatient total joint replacements at his facility, his staff was skeptical. The nurses and therapists he worked with didn’t want to move forward with early ambulation because they were concerned about pain and swelling levels. So, Dr. Sah personally returned to the hospital in the evenings to ambulate the patients himself.
“When they saw that I was willing to do this myself and I was a believer in it, the nurses took notice. They also saw how well the patients did when we ambulated them immediately and then could discharge patients within 24 hours, and then they were willing to make the switch,” Dr. Sah said. Over time, he was able to collect data on more than 100 consecutive knee replacement patients who underwent the outpatient protocol and was able to discharge 74 percent of them within 24 hours. This data set included all patients, not just those screened and selected for an outpatient procedure.
“The data showed me I had the right tools and program in place to transition knee replacements to the ASC successfully,” Dr. Sah said. To ensure the program remains successful, Dr. Sah tracks readmissions and complications among patients at the ASC, as well as pain scores.
An elevated pain score is a common reason for delayed discharge and early readmissions. Both Dr. Knapke and Dr. Sah employ multimodal pain management strategies to ensure patients are as comfortable as possible after surgery and minimize postoperative narcotic use.
“Narcotic use has gone down significantly within the last five to 10 years and that has been a good thing,” Dr. Knapke said. “The major reason why is we are much more able to control postsurgical pain because of the improvements in peripheral nerve blocks. The quality of peripheral nerve blocks and pain pumps has gotten better, and patients are waking up without much pain, allowing us to gain control of the situation.”
Dr. Knapke also significantly limits the amount of narcotics prescribed to patients after surgery, using multimodal analgesic techniques. He educates his patients about the potential side effects of narcotics and informs them that they will receive a limited number of pills to use judiciously.
Top-notch surgical system
Beyond pain management, another key aspect to achieving great outcomes is selecting the right surgical device and system. For knee replacement patients, it’s important to use an implant that will align with the patient’s anatomy and allow them natural range of motion without additional pain or instability.
“The Microport’s Evolution MP Knee System is one of the most stable on the market because of the medial pivot design,” Dr. Knapke said. “It’s a high-end knee, a top-notch knee to put into someone with high activity levels, like the otherwise healthy patients who undergo surgery at the ASC.”
There is growing interest in the Evolution MP Knee System in the national marketplace, said Dr. Sah, because it offers distinct kinematics when compared to other products. He reports his patients have less pain after knee replacements and request fewer narcotics, which he attributes to the implant design.
“That really makes the Evolution knee an ideal fit for the ASC and we see great results clinically,” Dr. Sah said. “Any one failure can undermine the success of the other aspects of outpatient surgery, and the Evolution knee has the characteristics necessary to optimize outcomes and to help your patients achieve a fast recovery.”
Some studies suggest up to 20 percent of knee replacement patients do not report a good to great outcome, according to a 2018 study published in HHS Journal.i In many cases, instability is the cause of dissatisfaction. However, Dr. Knapke doesn’t worry about instability with the Evolution MP Knee System. “I feel like I’m giving patients the best knee replacement I can give them. They trust the knee quickly because it feels solid to them,” he said.
Great patient communication
A third core concept for successful total joint programs in the ASC is established lines of communication during the postsurgical period. Dr. Knapke gives each patient his direct phone number, as well as the direct line to anesthesiologists, so patients have immediate access to him post-discharge. ASCs can also develop protocol for the initial communication with patients after they return home, increasing the touchpoints with clinicians during the postoperative period.
“We make sure to answer any discharge questions they have and keep in regular communication for two to three days after they return home,” Dr. Knapke said. “We also work with specific home health companies that know our expectations for protocols and communication. The home health specialists can text me any time with a concern about one of my patients, so we are all on the same wavelength around patient care.”
Discharge home and catching potential issues early to prevent readmissions is an important aspect of quality care, especially for those participating in bundled payments. To be successful in the bundles, Dr. Knapke said surgery should be performed in the ASC as much as possible and control post-acute care costs. “It all comes down to having the program in place and everyone being aware of the protocols,” he said.
Educating patients on the benefits of returning home after discharge can also reduce costs and complications related to being discharged to skilled nursing or rehab facilities. Home health agencies and outpatient physical therapy allow patients to return home with the same level of care.
“Because the time between surgery and discharge is so compressed with outpatient surgery, there are fewer interactions with the patient before they are on their way home, and they might feel abandoned if there isn’t enough communication,” Dr. Sah said. “It’s important that we bridge that communication gap with availability of our staff, who reach out by phone and encourage patients to text or email them with questions. Outpatient surgery is not about reducing their services, it’s about engaging them in a more cost-effective way.”
As the healthcare system moves more toward value-based care and bundled payments, the ASC will play an increasingly important role in surgeons providing high quality, low-cost knee replacement surgery. The pain management techniques and minimally invasive surgical systems, coupled with pre- and postoperative protocols to optimize patients, allow surgeons to perform more cases successfully in the ASC. However, they need the right partnerships, surgical systems, and mindset to achieve the best results.
Individual results and activity levels after surgery vary and depend on many factors including age, weight and prior activity level. There are risks and recovery times associated with surgery and there are certain individuals who should not undergo surgery.
These surgeons are paid consultants for MicroPort Orthopedics. The opinions expressed are theirs alone and do not necessarily reflect the opinions of MicroPort Orthopedics Inc.
This article is sponsored by MicroPort Orthopedics.
i Kahlenberg, C.A., Nwachukwu, B.U., McLawhorn, A.S. et al. HSS Jrnl (2018) 14: 192. https://doi.org/10.1007/s11420-018-9614-8