This week’s Orthopaedic Crossfire® debate was part of the 32nd Annual Current Concepts in Joint Replacement® (CCJR), Winter meeting, which took place in Orlando this past December. This week’s topic is “Outpatient TJA: “Drive-Thru” Surgery.” For the proposition is Michael E. Berend, M.D., Midwest Center for Joint Replacement, Indianapolis, Indiana. Opposing is Michael J. Dunbar, M.D., F.R.C.S.(C), Ph.D., Dalhousie University, Halifax, Nova Scotia, Canada. Moderating is Daniel J. Berry, M.D., Mayo Clinic, Rochester, Minnesota.
Dr. Berend: These are exciting times for us in arthroplasty. We talk a lot about implants and implant science and I think this will be a little bit more on procedure, protocol, and surgeon mental health, which is an ever important topic.
The four things to consider when you’re thinking about outpatient joint replacement are: the right patient, the right operation, the right surgical facility and the right surgical team. So it’s a multi-faceted decision to go down this pathway.
We’ve learned a lot about implants, fixation, various titanium, bone grafting, but I think that some of the anesthetic protocols have really led to same-day arthroplasty. This has happened for ACL reconstruction. It’s happened for many shoulder operations, upper and lower extremity sports medicine, foot and ankle, and even spine surgery now. So I think arthroplasty is following suit and for the right selected patients we’ve had great success in this space.
You may ask yourself, “Why do patients stay in the hospital.” I think there are three main reasons. The first is the fear or anxiety that goes along with having a major arthroplasty procedure; the fear of the unknown. The second is the risk or the co-morbidities associated with treatment; or medical complications that may follow. And then the third, and something we’ve really thought a lot about, is the side effects of our treatment. And these include narcotics; various anesthetic techniques where we don’t have a role in controlling anesthesia; blood loss with the admin of tranexamic acid; and some other techniques. These have been markedly reduced. And then some of the smaller incision operations lend themselves to this space as well.
Patient optimization is key. I think you need to develop a program to eliminate the need for staying in the hospital. We rely heavily on pre-operative education and pre-operative rehabilitation to make patients ready to discharge home the same day or within 24 hours. The second is pre-operative risk assessment. The third is mitigating the side effects of our treatment and establishing a lower complication protocol. And with this technique, over the last five years, 50-70% of all our patients are now done same day surgery.
This has developed a system with significant cost saving—roughly 30-40%. Episode cost is reduced through this type of pathway. It’s best for the overall health system, where the surgeon controls the environment. I think the number one value is that you control the environment for your team and your patient. It’s been transformative.
We rely on internists to help screen the patients pre-operatively. It’s important to have a pre-operative visit to the site, go through the educational program with physical therapy evaluation and then, obviously, have the family support at home. They need the same family support and the same education whether they go home the same day as the operation, or they go home the day after the procedure.
The right operation now for us is a very simple algorithm. Take out the diseased tissue and leave the normal tissue behind. We remove just the disease and a few years later, half of our patients now receive partial knee replacement. I think this is something to consider as you go into the outpatient space. The partial knee is three times less risky than it is to do a total knee replacement. I think picking the lower risk operation is ideal for the outpatient setting.
We’ve been able to reduce our instrument kits dramatically. We’ve done anterior lateral, posterior and direct anterior procedures, and doing what you do well is much more important than any super slick new technique. The best thing we’ve been able to do is work with anesthesia, the nursing staff, to standardize all our protocols so that it’s reproducible day in and day out.
Where to do the procedure? I think this is critical. Working in the hospital has led to my MMPI score to go down significantly. The use of the electronic medical record, death by committee, standardized mediocrity and all the things that the hospital environment has led to…at least in Indianapolis…have become a huge problem.
So a surgeon-controlled environment I think is critical. We began with outpatient in the ASC with two-year data and we performed just over 2, 000 knee arthroplasties with 98% of these folks going home the same day as the surgery. The average length of stay for knee arthroplasty is under four hours now. The proof is in the pudding. Using surgeon-reported quality outcome data, the readmission rate was 2%; half of these were for manipulation, very sundry medical complications—GI bleeds and so forth—and interestingly with our protocol no readmissions for pain control. So it can be done. It can be done safely in the right patients.
I think the future is now, just like we’ve gone for ACL reconstruction, upper extremity surgery…if you have the right patient, do the right operation, at the right location, with a coordinated surgical team, focus on the patient, their family and the recovery, patients embrace this concept. I think you’ll have to evaluate your local regulatory environment, insurance market and the like. I think you’ll find many more patients will qualify than you otherwise think.
Dr. Dunbar: When you’re asked to do a debate, or asked to look at any topic that we’re interested in, the first thing anybody would logically do is a literature search. And if you are really smart you will find somebody who’s already done that, and Dr. Brent Lanting, a colleague of Steve MacDonald’s at London, Ontario, was very kind to lend me his literature review on this which is coming out shortly, hopefully, in publication.
If you do your general search term using the terms largely hip and knee arthroplasty, and variations on outpatient arthroplasty surgery, what you end up with is a hit of about 805 studies. If you then put the inclusion criteria, very modest, very limited inclusion criteria—they have to be joint replacement, they have to be discharged within 24 hours, and they have to have reported at least one outcome metric. Of those 805 studies, we’re left with 17.
This is perhaps why this is such a controversial topic. Of the 17 studies, there is no randomized controlled study, zero, not a single one. And what we do have instead are 4 cohort studies which have a control group. So there are only 4 studies in all the literature that have a control group looking at this topic and what those studies reported is that patients do as well as with outpatient, with similar complication and readmission rates. So I’ll yield that to Mike. That’s what the data does say.
Within those 17 papers, there are 2 case-costing studies, and what they say is that on an average it saves about $2, 500 a case. So it may be cost effective as well.
Within those papers, however, there’s variability on the techniques, the procedures, the pathways, etc. Just take for example hip approaches… there’s no standardization, so as a surgeon/scientist it’s very difficult to take this data and make comparisons because it’s the proverbial apples to oranges comparison.
So, we’re left to rely on some anecdote opinion on what’s happening. And the problem, I would submit, with that is that it introduces a very significant proportion of bias.
In a paper that compares outpatient to inpatient total knee replacements, the exclusion criteria was interesting in that, importantly, diabetes and chronic pain requiring opioids—which is a big issue in Canada and a lot of our patients are diabetics—these patients were not candidates—as Mike alluded to in his talk. So within that paper’s series, 64 out of 150 were able to be entered, that’s around 43%, lower than Mike was reporting in the 60% range, but the point, clearly, is there is a selection bias on who’s receiving these procedures.
There are more examples. One of the startling things that come out of those 17 papers is that the majority of people getting the surgery are males when the incidences nationally and internationally are that more females than males get surgery. So there is a selection bias away from females that’s not explained in the literature and on average these patients are about five years younger than national cohorts who receive outpatient orthopedic joint replacement surgery.
I think the most important bias is who’s reporting the literature. And I would direct your attention to a very interesting study that came out of Europe (Labek G, et al) and looked at a comparison of outcome registries to surgeon-reported findings, in this case on specific implants. They found that the risk ratio for a positive publication compared to registry results was skewed in the favor of those who were designing the implants. And, again, I don’t think this is malignant and I would like to submit in this group capacity that it is benevolent bias on Mike’s behalf and he’s technically exceptional. He’s better than the rest of us. He’s high volume and all he does is arthroplasty. He has expert knowledge on the implant and system design. You heard that. He has very tight control of the pathway, which most of us long for. He has a high degree of control that surgical pathway and he has advanced insight and successful patient selection criteria.
In conclusion, we have limited data available on the topic. The data that is available is biased. Select patients operated on by select surgeons and select pathways, can have equivalent outcomes. Not superior, equivalent outcomes.
I think the message I want to get to the audience is don’t feel inadequate if you don’t do outpatient total joint arthroplasty. It’s an exceptional procedure for selected patients as I’ve alluded to. And if you’re going go there, I don’t think you have any right doing it unless you’re experienced, high volume, have tight control of your care pathway, and have some insight and experience with selecting these patients.
Moderator Berry: Mike, so tell us, what you’ve learned about the biggest problems that you’ve had and the pitfalls of doing this if somebody is interested in instituting this or thinking about doing it.
Dr. Berend: I think you really have to understand who your patients are, understand their medical comorbidities, manage every problem specifically—and if you miss that, say with sleep apnea, cardiac issues, under treatment for GI protection—you have to be ready to learn from that. What if the femur cracks? Are you ready to deal with that? What if things don’t go well with knee arthroplasty? You have to be ready to deal with that.
Moderator Berry: Michael, let’s grant that not every patient, of course, is a candidate for this, and you’ve listed many comorbidities, I think, that would disqualify them. But let’s grant that there might be some patients who are healthy enough that in theory they could do it. We know we can do a better job with pain control now than we used to. We don’t lose as much blood as we used to. We’re better at managing medical problems and finding healthy patients. So if it saves the system money and it allows the surgeons to have good control and create outstanding pathways, why not try it in a small group of patients? Can you articulate a reason why, if you have enough volume to get some patients to do it in, it would be a bad idea?
Dr. Dunbar: Right now in Canada we’re strapped, we have long waiting lists, and I think part of the danger is that my administrators pick up on these papers that Mike’s reporting on and they say, ‘Why aren’t you doing this? Because we need to shorten that length of stay or we need you to be more efficient.’ I get that. But it seems to me that my patients are getting sicker, they’re getting heavier, they’re getting older, they’re different patients now and I feel like a pilot—that’s a good analogy for Mike because he is a pilot—where I feel like they keep shortening the runway on me. I feel like I have to say, ‘If you shorten this runway one more foot, I’m not landing these planes here anymore because it’s not safe.’ I need a margin of error for these patients. So I think in Canada, for example, there may be a role to carefully introduce, with the right teams, bring someone like Mike up to mentor us, for very select patients to get in and out of the system quickly.
Moderator Berry: What are some of the main buckets of patients who you say just shouldn’t get this. There’s going to be the medical things—maybe you can mention those—but what about also home/social support because once they get home they’ve got to have a lot of help, right?
Dr. Berend: They have to be able to function independently with their stairs, their beds, their toilets, etc., so we go through all of that. Obviously, in the U.S., Medicare does not have an approved code to do an outpatient joint replacement, so immediately all Medicare patients’ primary hip and knee procedures are done in the hospital. And then other people are highly selected to go into this environment. We don’t try and talk people into this concept. If they want to stay in the hospital, we do it. If they don’t, we say, ‘Look you don’t need to stay in the hospital anymore, you’re welcome to go to the ASC. We think you’ll be home for dinner that night.’
Moderator Berry: Does this put a tough economic burden on the hospital because the hospital, of course, is getting everybody to use their Medicare or government payer – everybody who’s older, everybody who’s sicker, whereas the very healthy, young commercial paying patients are going to the outpatient centers?
Dr. Berend: As you might pick up, our relationship with the hospital is at a low point (laughter), so I don’t know the economic impact for them, but there’s been other historical things that have been long forgotten by the nine different administrators that I’ve related to that have led to this being good opportunity for us.
Moderator Berry: Great. Thank you both very much. It was interesting and something we’ll keep our eye on over the next few years.
Please visit www.CCJR.com to register for the 2016 CCJR Winter Meeting, December 14 – 17 in Orlando.
