Moderator Haddad: Keith, let’s first go to you. Is your clinic’s experience really translatable? Do you have a unique population in your area or do the patients self-select?
Dr. Berend: You’ve been to Ohio. We are in a big city. Our drawing area is roughly the majority of Ohio, which is relatively rural. I don’t think that it’s unique. I think that Midwest versus, perhaps, East Coast/West Coast, there may be some differences. The guys at NYU Langone are doing outpatient hip replacement there and doing a good job of it. I think it is translatable.
Country to country—what Alejandro said is very important. If your length of stay is multiple days right now, you will not be able to do safe ambulatory surgery Monday morning. If your length of stay has been going down and you’ve been working on rapid recovery, and you’ve been working on efficient care and things like that, it’s incredibly safe.
In order to capture all these in-hospital mortality/morbidity things you’d have to keep patients 5 days. First of all, no way in our health system can we afford to do that. Second, it’s just not fair to any of the stakeholders.
I think outpatient is very safe although it does require optimization of their health status. The things that you mentioned, like coronary artery disease, VTE, are all important.
Moderator Haddad: Alejandro, is there a signal on day 1 that tells you that this is a problem that’s going to happen day 3, day 4? Because you’re suggesting it’s going to happen in the perioperative period, but I know no one is keeping patients 5, 6 days. That’s just not realistic.
Dr. Gonzalez Della Valle: No question, there is a role for ambulatory surgery. But can it be used for the majority of patients? I reflect upon things that have happened to me in my own practice. I remember a patient undergoing medial uni-compartmental knee replacement that I kept overnight in the hospital and on the first night he developed a massive pulmonary embolism and needs to be immediately transferred to the intensive care unit to be able to make it out alive.
My concern is that at some point we will have a few healthy patients that will suffer these severe complications at home unexpectedly and if they have a negative outcome, it can give a negative impression of ambulatory surgery.
Moderator Haddad: One thing I see here as you shift all these young, fit, heathier patients to the surgery centers, the base hospital where you’ve traditionally based your practice, presumably get the less fit, less healthy, more expensive, more difficult patients. How are they going to survive?
Dr. Gonzalez Della Valle: That’s a very valid point. Inpatient hospitals are getting the sicker patients, patients who are generally Medicare and, obviously, lower reimbursement. Keep in mind also, if a hospital doesn’t own an outpatient medical center…you can be in serious financial trouble because the volume overall drops and it forces them to take the sicker patients.
