The Rush to Outpatient Arthroplasty Premature for Some Patients

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.

According to Barnett, the best tool to help select patients for outpatient arthroplasty is the Outpatient Arthroplasty Risk Assessment (OARA). He pointed to a study, “Safe Selection of Outpatient Joint Arthroplasty Patients With Medical Risk Stratification: the Outpatient Arthroplasty Risk Assessment Score” published in Journal of Arthroplasty in August 2017, which investigated the predictive ability of three scoring systems to select patients for outpatient arthroplasty, the OARA, the American Society of Anesthiologists (ASA) Class, or the Charlson Comorbidity Index (CCI). The OARA score was found to have the most precise predictive ability.

Barnett said, however, that the concern with the OARA is that it is a very long questionnaire with over 60 questions looking at various comorbidities, so it is significantly more time-consuming to complete than the other two scoring systems.

Creating a Protocol to Follow

For the best results, Barnett said you need a confluence of the right surgeon, the right institution and the right patient, such as an outpatient program at an inpatient facility with ambulatory surgery center-staffing, space and equipment, anesthesia modifications and appropriate patient candidates.

Barnett said that he and his colleagues at Hoag Orthopedic Institute used their in-patient experience, identifying the reasons patients were re-admitted and studying complication rates to create their own outpatient arthroplasty protocols.

First, they devote more time to the initial surgeon screening so they can make sure the patient meets the appropriate criteria including being active and motivated. They also use this time to inform the patient of the pathway and what they can expect.

Red flags that a patient is not a good candidate, Barnett said, include the 3 Ds—debilitated, demented and de-conditioned—and whether the patient is in a skilled nursing facility. Other factors to consider are whether the patient is overly anxious, has problems with pain management and/or has a non-supportive family. Barrett also doesn’t prefer to do outpatient arthroplasty on travel patients who are going to get on a flight right after surgery.

Next, patients identified as candidates for outpatient surgery must attend a mandatory pre-op education class which includes an orientation with physical therapy. And a “buddy” must attend and participate with them.

Barnett said that at his institution patients with any of the following are not a candidate for the outpatient pathway:

• ASA > II
• Unstable or poorly controlled chronic disease
• Hgb A1-C > 7%
• Chronic pain management
• BMI > 35
• Poor community ambulation
• History of pulmonary embolism or deep vein thrombosis
• Anxiety disorder
• Dementia
• No one to care for them in the first 72 hours post charge

“Physicians or med-level practitioners needs to discuss this with the patient prior to scheduling as outpatient,” he said.

Recovery Game Changers

Barnett said that making changes to anesthesia and patient diet also help patients recover quickly making them better candidates for same-day discharge.

“The complications that keep people overnight are not cardiac issues or pulmonary issues. It is basically related to anesthesia, spinal anesthetic issues and a big one is nausea. This was a game changer for us, changing our anesthetic and our diet,” he said.

“We tell patients they can have carbohydrate drinks up until an hour before surgery to decrease post-operative nausea and vomiting (PONV), insulin resistance, thirst, hunger and anxiety.”

Patients are allowed water, apple and cranberry juice, Gatorade and sports drinks, clear broth, Jello, coffee and tea without milk. Prohibited items include milk or dairy products, citrus juices, prune juice, juices with pulp, and alcoholic beverages.

Then in the recovery room they advance the patient’s diet immediately and start them back on regular food as soon as possible in order to reduce insulin resistance and decreases PONV and infection risk.

Patient Safety Must Be First

As of this past summer, the Hoag Orthopedic Institute had discharged 524 outpatient arthroplasty patients (16%) out of 3,259 total arthroplasty patients including hips and knees.

Of their 524 outpatient THA, two patients were readmitted, 1 for peri-prosthetic fracture and 1 for anemia. And while 80.9% of those selected for the outpatient surgery did go home same day, 18.4 % ended of spending the night in the hospital and 0.7% stayed in the hospital for 2 days.

“We have gotten more comfortable with this new pathway since it started in 2015 and are starting to include more patients,” he said. “And as of this summer when it comes to ASA scores between their outpatients and inpatients, 17% of their outpatients were ASA 1, 76% ASA 2 and only 7% were ASA 3. None were ASA 4. When it came to inpatients, 71% were ASA 2, 29% were ASA 3 and 0.4% were ASA 4. Patients in the outpatient program also had fewer comorbidities (3 vs 7).”

He added. “We have made a significant effort to keep people out of skilled nursing and acute rehab because by our own data, the readmission rate for any patients who go to any extended care facility goes up to 5 or 6-fold. We counsel patients strongly that they need to go home.”

“Patients who live alone, I strongly urge them to get somebody to stay with them for a few days, but even with that we do have 8-9% who go to extended stay facilities.”

The goal he said is to prevent readmission and emergency department visit after surgery, because not only does it increases cost, but it also negatively impacts patient safety and outcomes, which should be of paramount importance.

Dr. Barnett at the Direct Anterior Approach Hip Course

Barnett’s presentation, ““Outpatient Arthroplasty: I Want to Be Selective and This is Why” was originally presented at the International Congress for Joint Reconstruction’s 6th Annual Direct Anterior Approach Hip Course in 2017.

His presentation on outpatient arthroplasty was also on the agenda for the 7th Annual Direct Anterior Approach Hip Course which will be held September 27-29, 2018 in Houston, Texas.

The conference is designed for orthopedic surgeons and allied health professionals looking to learn the latest in orthopedic technology and optimum patient care when using the direct anterior approach to hip arthroplasty.

For more information, click here. (https://icjr.net/meeting/2018-7th-annual-direct-anterior-approach-hip-course) Or watch the live broadcast from the meeting here.