Thriving in outpatient joint replacements: 5 expert insights

Orthopedic surgery in ASCs has continued to accelerate over the past year. Looking ahead in 2021, Becker's ASC Review asked surgeons what they think is needed to thrive in the outpatient total joint replacement space.

Here's what five experts said:

Note: Responses have been edited for length and style.

Diane Litke, MD, orthopedic surgeon at Methodist Richardson (Texas) Medical Center: The key to successful outpatient joint replacements is good communication. That begins with the doctor-patient conversation and making the patient feel comfortable that he or she can go home the same day and be safe and comfortable, and that their pain will be managed.

Maintaining a team approach where all the healthcare professionals and the patient are on the same page and working together makes outpatient joints an efficient, comfortable and safe way to do surgery.

Thomas Myers, MD, orthopedic surgeon and assistant professor at University of Rochester (N.Y.): The short simple answer is we need an understanding from all parties that outpatient total joint arthroplasty is very different than inpatient total joint arthroplasty.

Currently, outpatient TJA has been largely embraced by stakeholders that are incentivized in one form or another to make it work. These incentives can be patient-driven and financial in addition to having the right supporting personnel and technology.

The average orthopedic surgeon does not have the correct incentives in place to safely take on the known additional work and risk involved with outpatient TJA. The margin for error in outpatient TJA is small in selecting the right patients, having the surgery go without complications, and rehabilitating the patient. Like most things, we need a strong team that has familiarity with each other — this includes the preoperative team, intraoperative team and postoperative team. This will require an honest and critical assessment of surgeon incentives to ensure the right combination of incentives are in place to insulate against unnecessary risk and additional work.

C. Lowry Barnes, MD, orthopedic surgeon at University of Arkansas for Medical Sciences in Little Rock: Hip and knee surgeons are moving more to outpatient, same-day discharge hip and knee replacement. As these procedures moved off the CMS inpatient-only list, more of these moved to observation status. Because of COVID and limitations on hospital beds, the natural progression to same-day discharge has occurred.

For surgeons, hospitals and surgery centers to be successful in this approach, patient selection and optimization prior to surgery is very important. At significantly lower reimbursement for these surgeries, they must also be performed efficiently and at lower cost. Implant prices will continue to decrease significantly. Communication via software platforms or traditional telephone calls will become much more important also. It takes a real team approach to successfully establish an outpatient same-day discharge total joint program.

Raj Pandya, MD, orthopedic surgeon at Atlanta Orthopedic Institute: The most important element that orthopedic surgeons need to thrive in the outpatient joint replacement environment is a comprehensive ecosystem that not only matches but exceeds hospital-based surgery experiences and outcomes. Specifically, this includes a physical plant which has to be large enough and accommodating to reduce infection and allow for other protocols to provide sterile environments, especially in the current setting.

The equipment should be available on-site and not brought in routinely for cases to reduce the risk of it not being available. It is critical to have a well-trained staff from intake to discharge including anesthesia and preoperative and postoperative nursing care, as well as surgical techs who are top class and driven to performing minimally invasive surgery, allowing for expedient and uneventful recovery.

It is necessary to be proactive in every aspect from pre-rehabilitation physical therapy to setting up appropriate home healthcare as needed. Most importantly, it is all about delivering an outstanding patient experience. When one begins with this in mind, the rest naturally flows. The surgeon should go over the entire procedure and experience from A to Z repeatedly in granular detail in their minds to assure success and avoid mistakes.

William Enright, MD, medical director at Orthopedic Surgery Center of the Fox Valley in Neenah, Wis.: This year presents unique challenges and opportunities for orthopedic surgeons performing total joint arthroplasty in the surgery center setting. COVID-19 testing protocols have enabled us to continue to safely perform these procedures at OSMS. Patients have historically sought out surgery centers as an alternative to hospitals due to the lower cost, but now they are doing so because of safety concerns.

The media have extensively covered the problems with availability of hospital beds throughout the country. This has made patients reluctant to schedule a surgery that may be canceled a few days prior.

As orthopedic surgeons, this helps us to safely perform more total joint arthroplasty procedures at surgery centers, especially when one considers that total hips are now approved in this setting. We should continue to educate patients and their employers that surgery centers are safe, efficient and more cost effective when compared to hospitals. If the movement for price transparency in healthcare continues, surgery centers will benefit.

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