Outpatient joint replacement requires a comprehensive approach

Richard A. Berger, MD
Richard A. Berger, MD

More patients are recovering from surgery outside of the hospital. A panel of orthopaedic surgeons discussed the myriad aspects of this shift for the surgical team and patients in the Monday, October 5, session Ambulatory Surgery: Transforming Inpatient Care to Outpatient Care across the Continuum. It will be available for on-demand viewing through the virtual Clinical Congress meeting platform through December 31.

Richard A. Berger, MD, assistant professor, Rush University Medical Center, Chicago, IL, is a world-renowned orthopaedic surgeon and a pioneer in minimally invasive joint replacement surgery. He shared lessons gleaned from the more than 11,000 same-day total joint replacements he has performed since 2004.

In 2019, 76 percent of Dr. Berger’s patients went home the same day as their joint replacement. In contrast, he said, 25 years ago it was considered immoral and irrational by many to decrease the hospital stay for total joint replacement from 14 days to just 10.

Since he pioneered outpatient joint replacement, it has been widely adopted.

“I think it’s helpful for the patients,” Dr. Berger said. “I think it’s helpful for the insurance companies. It’s helpful for the health care system in general.”

He explained that surgery is only part of the equation for rapid recovery.

“We need a comprehensive approach,” Dr. Berger said. “We have to marry surgery with pain management, and rehabilitation and education.” Each of these three components account for 20 percent of what makes rapid recovery work, he contends. “The other 40 percent you get from the synergy of all of these things together.”

Neil P. Sheth, MD, FACS
Neil P. Sheth, MD, FACS

Neil P. Sheth, MD, FACS, chief of orthopaedic surgery, Pennsylvania Hospital, and associate professor of orthopaedic surgery, University of Pennsylvania, Philadelphia, further detailed the steps needed to make the transition to rapid-recovery total joint replacement, starting with shortening patient stays following surgery.

There has been a dramatic increase in the number of patients who undergo total hip or knee replacement and are candidates to go home the same day or the morning after surgery, with one prediction suggesting more than half of knee arthroplasties will be done in an outpatient setting by 2026. Dr. Sheth estimates more than a third of these procedures are outpatient already. “We’re replacing joints faster, we’re replacing them in a cheaper fashion, and I think patients are doing better clinically,” Dr. Sheth said.

In 2018, total knee replacement was taken off the Centers for Medicare & Medicaid Services (CMS) Inpatient Only list, followed by total hip replacement in 2020. The outpatient reimbursement for the same procedures is lower than the inpatient reimbursement, saving Medicare money. The patient benefits too.

“Patients are able to get back quicker, they are able to use less resources of the health care system in order to be able to recover after surgery and be able to get back to doing what they want to do,” Dr. Sheth said.

He was one of the researchers for a University of Pennsylvania study that found discharge to home was associated with decreased early complications following primary total joint replacement compared to patients who went to a rehabilitation facility.

Another speaker, Tyler D. Goldberg, MD, orthopaedic surgeon, Texas Orthopedics, and affiliate assistant professor, department of surgery and perioperative care, University of Texas–Dell Medical School, Austin, reviewed how COVID-19 has affected ambulatory surgery center (ASC) operations.

Prior to the pandemic, outpatient joint replacement was an oasis in orthopaedics that explored how to encourage patients who were good candidates for going home sooner and how they could do so comfortably, he said. The four drivers of this were safety, patient satisfaction, economics, and more surgeon control over episode of care. In sum, he continued, the pre-COVID-19 focus was on outcomes and the patient experience.

“Post-COVID, it’s all about personal safety, and way down the list are we talking about outcomes,” Dr. Goldberg said. Patients want to know what has been done to minimize their risk of COVID-19 exposure and infection.

The American College of Surgeons (ACS) established a 10-step program for returning to the operating room following the suspension of elective surgeries early in the pandemic. With this guidance and with the goal of creating non-COVID care zones, Dr. Goldberg said, no-touch pathways have been established within his center to eliminate unnecessary exposure to patients and health care workers. When possible, steps leading up to surgery have been converted to virtual interactions.

Michael P. Bolognesi, MD, professor of orthepaedic surgery and division chief, adult reconstruction, Duke University Medical Center, Durham, NC, discussed outpatient joint replacement from the perspective of an academic medical center.