Dr. Gonzalez Della Valle: There’s no question that patient joint replacement can be done in an outpatient setting. The question is can Keith’s experience be extrapolated to other patient populations, urban or rural settings, or institutions with different practicing conditions—and do so without increasing the perioperative risks like readmission, local and general complications, but predominately life threatening ones and perioperative mortality.
The last 2 are very difficult to eliminate.
We will review these, their timing, who suffers them and the implications when patients sustain these complications outside the hospital. The majority of patients who die after a joint replacement do so of a heart attack, a pulmonary embolism, or a stroke.
A recent nationwide study demonstrated that time has to pass for the complications to happen—somewhere between 2 and 3 days. You have to wait 5 days to capture 75% of them (Gonzalez Della Valle A, et al., JBJS-BR, 2012; Bohl, HL, et al., CORR, 2017).
This nationwide data mimics that reported by Jay Parvizi in his own institution back in 2007 (Parvizi, J, et al., JBJS, 2007). What is most telling about this paper is that 58% of patients have those life threatening complications and had no identifiable preoperative predisposing factors. The steepest portion of a perioperative mortality curve occurs during the first 7 days (Jones, M, et al., JOA, 2014).
Hence, as Dr. Berend highlighted, they need to risk stratify patients to diminish mortality, which in my view, excludes a large proportion of total joint replacement candidates.
What’s not said are a number of underdiagnosed conditions we don’t routinely test for like coronary artery disease, genetic predispositions for thromboembolism and other sub-clinical conditions that can increase perioperative morbidity. In addition, anemia and progressive organ dysfunction can develop sometimes after the first 23 postoperative hours (Memtsoudis, S, Anesthesiology, 2009).
If you suffer a cardiac arrest out of the hospital in the U.S. the likelihood of surviving is only 10%. If a cardiac arrest occurs in the hospital, the survival rate is 25%. The feasibility of outpatient total joint replacement depends on a number of factors including current length of stay; your population’s general health, living conditions; availability of proficient visiting nurse services and the number of quality metrics of your emergency medical services.
With pulmonary embolism, which can have symptoms that linger, but are mild over a course of a few days, patients will present with over 3 days of the onset of symptoms, have worse right ventricle dysfunction and 4.3 times higher mortality rate (Yaser, J, et al., J Emerg Med, 2014).
With stroke, particularly ischemic of large vessels, there are only 7.3 hours from the onset of symptoms to the catherization suite if endovascular thrombectomy is needed for the patient to be less disabled (Saver, JL, et al., JAMA, 2016). Postoperative stroke has a 25% 1-year mortality rate (Mortazavi, J, JBJS, 2010).
I would finish by asking you to exercise caution in creating very high expectations for patients and payers. At the end of the day, hip and knee replacements are not minor surgeries.
The term “ambulatory” may give some patients a false sense of safety and may give our government and payers the impression that the time we spend caring for ambulatory total joint replacement patients is less than when they are needed for a couple of days, which is not necessarily true.
