What to know before starting an outpatient total joint program: Illinois Bone & Joint Institute's Dr. Brian Schwartz weighs in

Brian Schwartz, MD, orthopedic surgeon at Illinois Bone & Joint Institute, shared his input on outpatient total joints with Becker's ASC Review.

Note: Responses have been lightly edited for style and clarity. 

Question: What changes or opportunities are you expecting to see for outpatient total joints?

Dr. Brian Schwartz: It's definitely a growing segment of the portion of total joints that we're doing. With the new CMS rules in 2020, we'll be able to perform Medicare patients’ total knees as outpatients. Obviously not all Medicare patients are meant for the outpatient total joint replacement, but there's certainly a percentage of  patients that are healthy enough to be treated in an outpatient setting. I think outpatient total joint replacement is definitely the future and will continue to grow.

Q: What would you say is the biggest threat or competition for doing these procedures?

BS: I think the biggest threat or competition would be doing procedures in the hospital setting. But I would argue that doing it as an outpatient has several key advantages. In theory, you have a smaller risk of hospital acquired infections, which is a devastating complication and anyway to minimize this risk is of the utmost importance. Costs are also becoming more transparent. Going forward, hospital systems and outpatient surgical centers are going to be required to put the cost of the total joint episode online for the market or for patients to see. I think that's going to make it very difficult for hospitals to compete.

I think patients will see the very stark difference in costs, and this will drive even more patients to the outpatient setting. Regardless of cost, I would argue if given the option most patients would prefer to recover in the privacy and comfort of their own homes. Lastly, I’ve found that in the ambulatory setting the surgeons have much greater control of the process from beginning to end. Whether it be ensuring we have the anesthesia and OR team we desire, to instituting protocols founded in evidenced based medicine, to avoiding the red tape and bureaucracy that can be seen in hospitals.

Q: Is there any technology or advances in procedures that you're excited for on the horizon?

BS: There's definitely a trend to move toward the direct anterior approach for total hip replacements. While this is a hotly contested topic among some arthroplasty surgeons, there is orthopedic literature that would suggest the direct anterior approach is associated with a slightly quicker recovery in the short term in terms of pain control and getting rid of assistive devices such as a walker or cane quicker.

I also see a trend in how we manage the patient perioperatively from using multimodal pain management, trying to avoid narcotics, and using alternative methods such as spinal anesthesia, periarticular injections, and regional blocks. Things like this I think are allowing us to do more and more total joints in an outpatient setting.

Q: With pain management, do you see more of a shift away from opioids? How is your practice dealing with the opioid issue?

BS: We use what is called multimodal pain management, meaning we use different medications that help attack pain in different ways, with the goal to minimize or completely avoid narcotics. That doesn't happen for all patients, but as the opioid epidemic becomes more and more in the public view, both patients and physicians are becoming much more cautious with the use of opioids.

Q: Are there any kind of overarching trends that you're seeing right now in outpatient orthopedics?

BS: Looking at my practice, I see more patients coming in requesting to have their surgery done as an outpatient. I think that's a stark difference from what was seen five or 10 years ago. As more and more total joints are done in the outpatient setting, I believe this is lifting some of the anxiety that patients initially had with outpatient hip and knee replacement. I think as patients become aware that this is an option, [outpatient joints] will continue to steadily grow.

Q: Do you have any tips or things to know before starting a total joint program?

BS: I think the most important thing is patient selection. You need to have a healthy patient, a motivated patient, someone that has a good support system at home that can help carry them through the first couple of days of recovery.

Then you need to have a good team around you. It starts with anesthesia and the surgeon, but it's also important to have a physical therapy team and a post-op nurse that's experienced in getting people up and moving right away. Also, a trusted experienced home health RN and physical therapy team is an essential element to the process. We're trying to break down the culture that if you have your hip or knee replaced you need to be in the hospital for two or three days because that is definitely no longer the case.

If someone is starting this de-novo, I would recommend to travel to a center that's been doing this for a long time and see in person the process from beginning to end. That way they're not reinventing the wheel from scratch because it's being done successfully across the country.

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