This week’s Orthopaedic Crossfire® debate was part of the Annual Current Concepts in Joint Replacement® (CCJR®), Winter meeting, which took place in Orlando. This week’s topic is “The Outpatient THA: A Paradigm Change.” For is Keith R. Berend, M.D., Mt. Carmel New Albany Surgical Hospital, New Albany, Ohio. Opposing is Jay R. Lieberman, M.D., Keck Medical Center of USC, Los Angeles, California. Moderating is Thomas S. Thornhill, M.D., Harvard Medical School, Boston, Massachusetts.
Dr. Berend: It’s something that is clearly near and dear to my heart.
We’ve tried to understand what patients need or why they need to stay in a hospital. And it all boils down to three factors, in our experience.
First is the fear and anxiety. Mostly the fear of the unknown or the dogma of the fact that you just stay in the hospital with this operation.
It boils down to the risk and that risk is defined by the comorbidities and medical complications that occur with the operation.
And then the side effects of what we’re doing to the patient and that mostly revolves around anesthesia and the avoidance of narcotics. The issues of blood loss, particularly with total hip replacement, and then the surgical trauma.
If you look at fear, it’s the unpleasant emotion caused by the belief that something is dangerous, likely to cause pain or a threat. So, to address fear, you must educate the patient. You educate the patient preoperatively what to expect; when they’re expecting; educate the family—“How am I going to bring Mom or Dad or husband or wife home the same day of surgery?” That’s a very easy hurdle to overcome.
The second hurdle is pre-arthroplasty rehabilitation. Again, it goes to education. Over the last two decades we’ve shown that pre-arthroplasty education reduces that fear and anxiety. It also decreases pain and improves outcomes.
Risk is defined as a situation involving the exposure to danger. What we must do here is decrease the exposure to danger.
How do we do that? We do that through what’s called preoperative medical optimization. It used to be called preoperative clearance and that’s not what we’re trying to do. What we’re trying to do is optimize the patient’s medical situation such that they can have an operation—and these are elective operations, regardless of how we look at it.
If you’re having an elective operation you ought to be well enough to have it done as an outpatient. There’s been a lot of discussion about how we identify these patients and it’s boiled down to a very, very simplistic idea. And that is do you or do you not have an organ failing? If you don’t have an organ failing, then you can have this done as an outpatient. Very simple.
If we look at the side effects, we’re looking at the undesirable effect of a drug or medical treatment. Basically, what we’re talking about is going through a laundry list…a very well-articulated laundry list of how to avoid or reduce the amount narcotics the patient takes preoperatively, intraoperatively, and postoperatively.
MIS does not mean minimally invasive surgery. It doesn’t matter. The surgical approach doesn’t matter. The operation itself doesn’t matter. It’s the skillfulness in avoiding wasted time that defines what is called minimally invasive and it’s basically the efficiency of the operation.
It’s important to understand why this is occurring and the multiple stakeholders that are involved. It involves the cost, control, the surgeon, the patient, and the health system. All these come together—and there’s no other way to define it—when all these things come together it equals outpatient arthroplasty.
There have been multiple studies which show significant cost savings and significantly better reimbursement in terms of cost-to-reimbursement ratio by doing these procedures as an outpatient.
A recent study showed almost a $7,000 cost savings per procedure for the system—which can be enjoyed by all stakeholders.
