There are more high-acuity orthopedic procedures going to the outpatient setting today, including total joint replacements. Orthopedic technology is developing for minimally invasive procedures, and new pain management protocol and post-surgical care allow patients to leave the outpatient centers within 23 hours after surgery.
"It's been a natural progression over many years where we have seen a gradual reduction in the duration of hospital stay after joint replacement," says Robert Greenhow, MD, of Peak Orthopedics & Spine in Lone Tree, Colo. "This has been based on less invasive and improved surgical techniques, use of regional anesthesia and peri-articular injections, less tubes and drains and a reduction in the use of narcotics."
Outpatient surgery benefits
The direct anterior approach has become a powerful tool in the realm of outpatient hip surgery. Surgeons are able to approach the hip anteriorly for less blood loss and postoperative pain, which makes rehabilitation quicker and easier.
There was a study performed in Washington showing more consistency with cost-per-case with the anterior approach when compared to the lateral approach. The anterior approach was also associated with reduced time in the operating room.
"Over the past few years, most of our anterior approach hip replacement patients were being discharged from the hospital within 23 hours," says Dr. Greenhow. "It was a natural transition to move some of our younger, healthy patients into the outpatient center."
Drs. Loucks' and Greenhow's ambulatory surgery center offers the same surgical team, anesthesia and implants at the ASC as they do at the hospital, but the outpatient center is a more intimate setting with an environment designed to optimize personalized care.
"These outpatient centers are usually much less intimidating for patients compared to large, acute care hospitals," says Craig Loucks, MD, of Peak Orthopedics & Spine. "Most patients are amazed at how good they feel after surgery and how mobile they are just a few hours postop."
The infection rates are also historically lower in outpatient surgery centers and patient satisfaction is higher. One study comparing anterior and posterior approaches in the same patient — one hip was posterior and one hip was anterior — shows the patient preferred the anterior approach. When patients are satisfied, they refer their family and friends.
"There are numerous clinical benefits to the anterior approach for patients," says Dr. Greenhow. "These benefits have been determined through prospective, randomized trials and other peer-reviewed literature. These benefits include less muscle and tendon damage, lower dislocation rates, less pain early on, shorter requirement for a walking aid, earlier return of muscular strength, quicker return of normal gait and quicker return to work."
But not every patient is well-suited for outpatient procedures. "Currently, our outpatient joint replacement practice is limited to younger, healthy and motivated patients," says Dr. Greenhow. "Most commercial payers are participating but not government-based payers, such as Medicare, at this time."
Since Medicare won't reimburse for outpatient total hip replacements in the ASC, even healthy patients older than 65 are taken to the hospital. "Eventually it is conceivable that Medicare and other government plans will recognize the tremendous clinical and economic benefits of outpatient joint replacement," says Dr. Loucks.
Dr. Loucks and Dr. Greenhow counsel their patients on outpatient surgery options, and some patients arrive at their office already requesting surgery in an ASC.
"The majority of patients are thrilled at the prospect of going home the same day of surgery," says Dr. Greenhow. "Having done outpatient joint replacement for over two years, we have more and more patients coming to us specifically for the outpatient program."
Economic benefits
In addition to the clinical benefits, taking cases to outpatient surgery centers also have an impact on the healthcare economy. ASCs cost less than performing cases in hospitals—even hospital outpatient departments—and the lower infection and complication rate means there is less spent on additional healthcare to fix those issues.
The ASC doesn't have the same infrastructure needs as the hospital, so cases can be done more efficiently and cost-effectively.
"We believe outpatient joint replacement surgery is a great example of how we can control costs while maintaining or perhaps improving quality in these new settings," says Dr. Greenhow. "Outpatient joint replacement in the right patients will eventually become the standard of care."
The country is moving more toward value-based care, paying close attention to quality and cost metrics. This shift in healthcare philosophy will drive the move to outpatient surgery centers. But, the transition isn't always easy.
"Our first and biggest hurdle was convincing the hospitals and insurance companies," says Dr. Loucks. "Traditionally these cases have always been performed in an inpatient hospital setting. Often, getting approval by the insurance carrier to perform these procedures in an ASC can be a challenge. However, this is improving. Insurance carriers are slowly recognizing that these cases can be performed safely and effectively in an ASC setting."
Since these cases are reimbursed less in the outpatient ASC, hospitals stand to lose money from the transition. However, some hospitals are partnering with physicians for joint venture surgery centers to retain a percentage of the reimbursement and form a relationship with the surgeons in their community.
"We believe that those hospitals systems that embrace and support this trend proactively will fare well long-term," says Dr. Greenhow. "Hospitals and ASCs can successfully partner with surgeons to help control costs and improve outcomes."
Making the transition
The preoperative and postoperative protocols are similar for the ASC and the hospital, making the transition smooth. If surgeons have experienced staff around them in both settings, their workflow doesn't change much.
"Really the only difference is the location where we perform the surgery and the mindset of the staff and expectations of the patient," says Dr. Loucks. "The ASC staff is accustomed to early mobilization and same-day discharge."
There are tools that can improve the procedure; a special operating table facilitates the procedure, but it's an expensive capital expenditure.
"Medacta provides a leg positioner for all cases and this can be a nice opportunity for surgeons and ASCs where the capital cost of an expensive, special operating table is prohibitive," says Dr. Greenhow.
There is a learning curve for new surgeons incorporating the anterior technique in their practice. Some surgeons find the learning curve so steep they abandon the technique and revert back to the posterior approach.
"A formal education program is important for new adapters where they can visit a reference center to watch live surgery — we have visiting surgeons almost every week in Denver; attend a cadaveric lab course; and then have a surgeon come to their hospital to help proctor them on their first cases," says Dr. Greenhow. "Medacta International has been a leader in the field of anterior approach hip replacement education. They have a very comprehensive educational and proctoring program with a very high conversion rate for surgeons adopting the anterior approach."
Both Dr. Loucks and Dr. Greenhow have trained hundreds of surgeons over the years on the anterior approach to hip surgery. The muscle-sparing technique, combined with intra-operative X-ray guidance, can have excellent results.
"Once these surgeons have mastered the technique, they have reported improved implant position, accurate leg length reduction, earlier discharge home and improved patient satisfaction," says Dr. Loucks. "Our technique has evolved significantly over the last 11 years and we are at the point where we truly are muscle-sparing in our AMIS approach. In the anterior hip world, we are seeing variations in the technique that have surgeons cutting selected muscles and tendons to get exposure and perform the subtle, yet important, details in surgical technique will likely be differentiated clinically over the years to come."
This article is sponsored by Medacta.