With the already high demands on the United States healthcare system, the push to perform more surgeries on an outpatient basis is not unexpected, but Steven L. Barnett, MD, an orthopedic surgeon with the Hoag Orthopedic Institute in Irvine, California, says that this doesn’t mean that outpatient is the best option for every patient.
Barnett, in his own practice, is selective when choosing patients for outpatient arthroplasty in order to provide his patients the best outcomes possible.
Barnett explained that the number of arthroplasties being performed in an outpatient setting is still on the smaller side. According to a 2017 American Academy of Orthopedic Surgeons/American Association of Hip and Knee Surgeons Specialty Poll on outpatient total hip arthroscopy (THA), 28% of those polled did some outpatient THA and 72% only perform inpatient THA.
Barnett said that the main reasons to choose outpatient THA are space issues, patient demand, market pressure, and a push for more value-based care.
He explained that at his institution, starting an outpatient arthroplasty program was attractive because they only have 70 beds so space is limited. And like other medical institutions they were being pushed to decrease healthcare spending while still maintaining quality. Commercial bundled payment, Medicare bundles and the Centers for Medicare and Medicaid Services (CMS) moving total knee arthroplasty to the outpatient list all played a role.
He added that more patients are preferring outpatient arthroplasty as well. Younger and more active patients don’t understand why they need to stay overnight at the hospital. Younger surgeons also tend to prefer doing outpatient procedures because it helps to build up their practice.
Despite all the benefits to the outpatient route though, Barnett offers words of caution. “When it comes to value, we can’t just consider cost, we have to also consider patient safety.”
Recognizing Risk Factors
According to Barnett, key literature on outpatient arthroplasty shows that it is a safe option, but despite the positive data, physicians need to only choose healthier patients for outpatient care.
One study, “Complications Following Outpatient Total Joint Arthroplasty: An Analysis of a National Database”, published May 2017 in the Journal of Arthroplasty, reported that outpatient total joint arthroplasty (TJA) alone did not increase the risk of readmission (OR 0.652, 95% CI 0.243-1.746; p = .395) or reoperation (OR 1.168, 95% CI 0.374-3.651; p = .789) and was a negative independent risk factor for complications (OR 0.459, 95% CI 0.371-0.567; p < .001). However, the researchers still concluded that while outpatient TJA is a safe option, it should only be performed in select, healthier patients.
Another study, “Predictors of Same-Day Discharge in Primary Total Joint Arthroplasty Patients and Risk Factors for Post-Discharge Complications”, published in the September 2017 issue of the Journal of Arthroplasty, found similar results.
Out of a total 120,847 primary total joint arthroscopy patients, only 7,474 were discharged within 24 hours post-surgery, and these patients were more likely to be younger, less likely to be obese, and have less co-morbidities.
In addition, in the study, “Feasibility of outpatient total hip and knee arthroplasty in unselected patients” published in Acta Orthopaedics in October 2017, the researchers reported that female sex and surgery late in the day increased the odds of not being discharged on the day of surgery. Of the 54% of 557 patients considered potentially eligible for outpatient surgery, only 13% to 15% were actually discharged the day of surgery.
Similar words of caution were given in the study, “Same Day Total Hip Arthroplasty Performed at an Ambulatory Surgical Center: 90-Day Complication Rate on 549 Patients” in the Journal of Arthroplasty, published in April 2017. Though they operated on large number of patients and didn’t have a high rate of complications, the researchers still felt strongly that the outpatient pathway isn’t for every patient. If there are any doubts, the procedure should be done as an inpatient.
The study included 549 consecutive patients in the ASC (ambulatory surgery center) setting (non-Medicare) which was 12% of all TJA patients (4,669). The average length of stay (LOS) was 7.5 hours, with 1 ER visit (0.2%) and 3 re-admissions (0.5%). Inpatient complication rates were not reported in this study.
