Care Process Redesign

The Rise of Outpatient Joint Replacement

August 10, 2017 10:24 am

Although joint replacement surgeries will increasingly be performed as outpatient procedures, inpatient volumes are expected to hold steady.

Joint replacement surgeries will continue to move to the outpatient arena, but many hospital operating rooms will stay busy with the procedures for the foreseeable future.

“The sky is not falling,” says Sebastian Beckmann, a consultant in the Advisory Board’s research division. “We do expect growth in outpatient joint replacement surgeries, but this trend isn’t going to disrupt your whole business model. We also expect growth for these procedures in the inpatient setting.”

That said, he and others encourage hospital leaders to consider partnering with surgeons who may already perform joint-replacement surgeries in ambulatory surgery centers (ASCs) or plan to start doing so in the foreseeable future.

Total joint replacement (TJR) surgery in an outpatient setting is only appropriate for certain patients—otherwise healthy people with adequate support at home to facilitate recovery. Those are the patients that seek out physicians like Craig J. Della Valle, MD, professor of orthopedic surgery and chief of the Division of Adult Reconstructive Surgery at Rush University Medical Center in Chicago. About 25 percent of the TJRs he performs are outpatient procedures at an ASC, of which he is a part owner.

“Ten years ago, patients would come in and say, ‘My friend told me that if I had my joint replaced, I would need to go to a rehab facility,’” he says. “Now patients are coming in and saying, ‘You did my friend’s surgery and you did such a good job, he didn’t need to stay in the hospital.’”

In North Carolina, where four large orthopedic practices recently came together as EmergeOrtho, one surgeon started performing total hip replacement surgeries as outpatient procedures at a physician-owned hospital two years ago. More recently, several colleagues started doing hip and knee replacements at a physician-owned ASC.

At EmergeOrtho, which has more than 150 physicians working in 49 clinics in 21 counties, staff members have developed new protocols and support infrastructure to accommodate the outpatient procedures, with the expectation that they steadily will become more common.

“This is going to become the norm in the next five years,” says Chris Zito, EmergeOrtho’s manager of bundled programs. “It’s just a lot easier to get patients into therapy as quickly as possible and get them on the road to recovery—even quicker than it would be if they stayed in the hospital just one or two days.”

Where We Are Now

Hospital stays after TJR have been declining in conjunction with improvements in pain management, surgical techniques, and post-operative patient care. The Centers for Medicare & Medicaid Services (CMS) reports that the average length of stay (LOS) for an uncomplicated total knee replacement fell from 4.6 days in 2000 to 2.8 days in 2016, according to Sg2, a consulting firm.

The same factors that are shortening inpatient LOS prompted some surgeons to push the procedures into the outpatient setting. Here and there across the country, surgeons have been performing outpatient knee and hip replacements for many years, although the phenomenon has been slow to gain traction. A review of 2015 data for 279 hospitals that are members of the Advisory Board found that 55 were doing joint replacements on an outpatient basis, but only five had significant volume.

Beckmann cites two reasons: Few ASCs have invested in the staff and infrastructure to accommodate outpatient joint replacement procedures, and CMS, which pays for about half of all joint replacement surgeries, does not pay for outpatient TJR.

The biggest reason, however, is that the majority of patients are not good candidates because of obesity, poor conditioning, or unstable chronic conditions. “It’s really incumbent upon the surgeon to pick and choose correctly,” Della Valle says. “You want patients who are healthy and self-aware and have a reasonable support network” to help them recover at home.

Another limiting factor, Della Valle says, is that surgeons who perform TJR less frequently prefer hospital operating rooms in case complications arise. “Surgeons who specialize and do these procedures frequently are probably more comfortable doing them in ambulatory settings than surgeons who do them less frequently,” he says.

Where We Are Headed

As the value movement in health care takes hold, outpatient TJR will attract ever more attention because it costs less while offering comparable outcomes. Researchers who surveyed 235 TJR patients—137 had outpatient surgery; 98 met the criteria for outpatient surgery but were treated as inpatients because of surgeon preference—found that the outpatients had a statistically insignificant higher rate of unplanned 30-day readmissions (Springer, B.D., et al., “Impact of Inpatient Versus Outpatient Total Joint Arthroplasty on 30-Day Hospital Readmission Rates and Unplanned Episodes of Care, Orthopedic Clinics, January 2017).

Outpatient TJR eventually will become the standard of care, according to Sg2. It predicts that more than half of all primary hip and knee replacements will be performed in hospital outpatient departments and ambulatory surgery centers by 2026. (“Outpatient Joint Replacement: An Unnecessary Concern or Market Reality?” Nov. 8, 2016, Vizient.)

The consulting firm forecasts a 77 percent increase in joint replacements by 2026, but many patients will not be candidates for outpatient procedures. So inpatient TJRs will still grow by 3 percent within the decade, even though outpatient TJRs become the norm.

Outpatient Versus Inpatient

The outpatient versus inpatient comparison conducted by Springer and his colleagues found that a significantly higher proportion of those who had an outpatient TJR reported excellent care on the day of their surgery. That finding resonates with Della Valle, who says ASCs are patient-satisfiers by design.

“The patients are tended to very carefully, and they notice that,” he says. “The number of patients who are very highly satisfied at the surgery center is higher, not only because the service level we provide is high, but also they are there for such a short period of time that there is less chance for something to upset them in some way.”

EmergeOrtho—formerly known as Triangle Orthopedics—has been fine-tuning its processes and protocols for joint-replacement surgeries ever since it joined Medicare’s Bundled Payments for Care Improvement (BPCI) program in 2015.

“That has been a huge driver in the way that all these practices think about patient care, pre-operatively and post-operatively,” Zito says. “That was a big game changer across the board.”

In EmergeOrtho’s view, two protocols are essential for success in outpatient surgery patients, who must be proactive in their recovery and rehabilitation.

Mandatory attendance at a joint class offered by the surgery facility. The class educates patients and their caregivers about the logistics—what time to arrive at the hospital and where to check in—and what to expect during rehabilitation and who to contact with post-surgery questions or concerns.

A required “pre-therapy” appointment at the rehabilitation facility. The patient is given exercises to do both before and after surgery. “Also, this connects you with the therapist so you know who you’re going to go back to after the surgery,” Zito says. “That starts a continuity between you and that therapist at the clinic.”

Patients treated in the ASC arrive at the hospital at 6:30 a.m. for 7:30 a.m. surgery—and discharge before 1 p.m. Durable medical equipment—for example, a walker, a cane or other equipment—is given to the patient’s family caregiver before the patient heads home.

A home health aide meets the patient and family at the surgery center, then follows them to their home. The aide helps the patient get into the house safely and gets everything in place—ice, medications, meals—to support recovery at home.

The goal is to ensure patients and their home caregivers understand how to manage pain and who to call if they need advice. “We want the patient to stay away from ED [emergency department] visits,” Zito says.

Physical therapy already is scheduled for the first day after surgery, so patients return to the outpatient rehab facility and the therapists they met with before the procedure and rehabilitation is underway.

Getting Ready

Zito has been contacted by hospital administrators wanting to know how their facilities can accommodate outpatient TJRs. He says it is possible, but will require buy in from nurses, discharge planners, case managers, and others, all of whom will have to adjust their practices. His main advice: This is not about speeding up hospitals’ routine ways of caring for surgery patients.

“This means writing new protocols for patients who are going to be leaving the same day to make sure they get more eyes on them than other patients,” he says. “These patients are different, so you do need to change your processes.”

Interviewed for this article:

Sebastian Beckmann, is a consultant, research, Advisory Board, Washington, D.C.

Craig J. Della Valle, MD, is chief, Division of Adult Reconstructive Surgery, Rush University Medical Center, Chicago.

Chris Zito, is manager, bundled joint programs, EmergeOrtho, Raleigh, N.C.


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