Two orthopedic surgeons told Becker's ASC Review about how surgeons can create strong outcomes for total joint replacements in 2021.
Note: Responses have been lightly edited for style and clarity.
Thomas Obermeyer, MD, orthopedic surgeon at Barrington Orthopedic Specialists (Schaumburg, Ill.): The coronavirus pandemic has generated a heightened demand for the shift of joint replacements to the ambulatory setting. Orthopedic surgeons will play a key role in sustaining this shift after the pandemic abates, as it is becoming clear that joint replacements can be performed safely and effectively at ASCs with high levels of patient satisfaction.
Key in the performance of outpatient joint arthroplasty is a team approach to patient selection and education, that begins with the surgeon, preoperative physical therapy evaluation, and, importantly, medical optimization by the [primary care physician], nursing, and anesthesia to minimize the risk of complications.
For the surgeon, we can continue to hone our pain management regimens to ensure the patient is comfortable for discharge the day of surgery and for the early recovery at home. Skilled anesthesia providers offering regional and spinal anesthesia, and intra-articular cocktails are two important ways to limit opioid exposure. I have seen benefits of liposomal bupivacaine mixed with dexamethasone for longer interscalene block duration for shoulder replacements.
Lastly, surgeons can focus on data collection to demonstrate the safety and favorable outcomes of these ambulatory procedures in their own practices. Payers will rely on this data to approve and even incentivize the shift of replacements to the outpatient setting. Some payers, especially Medicare, have been slow to adapt, which limits ASC access by their beneficiaries. We can advocate for our patients by collecting the data that supports our clinical decisions
David Fehnel, MD, orthopedic surgeon at Sports Medicine North (Peabody, Mass.): The best outcomes are with high-volume surgeons. The development of non- or minimal-opioid postoperative pathways also have made outpatient joints successful. This has been in conjunction with pre-op periarticular field blocks for post-op pain.
Most outpatient total joints are being performed in physician-owned surgical centers where the orthopedic docs have full control over the patient's total joint experience and a financial interest in the patient having the best outcomes. Very few hospitals have or will closely involve the surgeons financially in the delivery of total joint care where the surgicenters give the physicians complete transparency in both cost and the patient's satisfaction of their care so that everyone is aligned.
Another continuous problem with hospitals has been the closure or limitations of OR time as hospitals have had high COVID-19 case numbers or have allowed staff to be taken away to back-fill nursing shortages. The surgicenters have given an equal or better environment to perform these cases at a high level.
Another driving factor will be the decreased reimbursement by Medicare and potential commercial payments to the surgeons, which will drive more cases to outpatient centers.