Becker's ASC Review

38 Executive Briefing Sponsored by: A cross healthcare, significant transformation is making care more accessible, available and convenient for patients. One of the most visible changes within the healthcare ecosystem has been the evolution and growth of same-day outpatient surgical centers. This shift has enabled care providers to provide greater convenience while helping to address costs and nosocomial complications associated with in-hospital procedures. Richard Berger, MD, and colleagues from Chicago-based Rush Orthopaedics pioneered an outpatient approach for total knee arthroplasty with minimal complications in 2005. 1 Initially met with skepticism, a growing body of prospective clinical trials supports this as a safe and effective management strategy. Importantly, outpatient joint replacement may reduce the total cost of care by over 20 percent. 2 With value-based care initiatives increasingly facing orthopedics, the specialty is rapidly adopting this trend for hip and knee replacement with current projections estimating orthopedic surgeons will perform the majority of these procedures in ASCs by 2026. 3 While the service model may be new, the treatment goals remain the same for surgeons: achieve improved patient functionality while minimizing the potential for postoperative complications. Early investigators realized the challenges of rapid discharge and therefore developed rigorous pathways to optimize outcomes through standardized patient selection and process of care. Unfortunately, the translation of outpatient joints from academic clinical studies to community practice has faced challenges. An analysis of the Medicare claims database from 1997 to 2009 found outpatient joints had higher risk for major complications, revisions, readmissions and mortality at 90- days, 1 year and 2 years. 4 Armin Arshi, MD, and colleagues from UC Los Angeles replicated this finding based upon data from Humana's insurance claims dataset. Specifically, outpatient joint replacement patients were 1.5 times more likely to need subsequent irrigation and debridement procedures and 1.35 times more likely to need explantation of their prosthesis than those who had their procedure performed inside a hospital. 5 The consequences of failing to properly translate these pathways can devastate the finances of an ASC, especially when the center participates in a bundled care model. Readmission for deep infection within 90 days increase costs between $24,000 and $32,000 while readmission for periprosthetic fracture may cost as much $55,000. 6 Each complication could wipe out the contribution margin afforded by eight to 18 cases. 7 Successful arthroplasty surgery is dependent on a number of factors including: the individual patient as well as the skills and experience of the surgical and postoperative team. Materials and methods also play an important role and cement and cementing technique are critical. Use of cement Cemented total joint procedures have better outcomes for both hip and knee replacement patients and this advantage is particularly pronounced in patients aged 65 and older. 8 With the early ambulation required in the outpatient setting and increased risk of periprosthetic fracture, bone cement plays an important role in ASC joint replacement. The economic value created by bone cement increases given the cost of cementless implants, which can be several thousand dollars more than cement-based implants. Best practices for reducing complications & revisions in ASCs 1 Berger RA, Sanders S, Gerlinger T, Della Valle C, Jacobs JJ, Rosenberg AG. Outpatient total knee arthroplasty with a minimally invasive technique. J Arthroplasty 2005; 20(7 Supply 3): 33-8. 2 Aynardi M, Post Z, Ong A, Orozco F, Sukin DC. Outpatient Surgery as a Means of Cost Reduction in Total Hip Arthroplasty. HSSJ 2014; 10: 252-5. 3 Impact of Change® v16.0; HCUP National Inpatient Sample (NIS). Healthcare cost and utilization project (HCUP). 2013. Agency forHealthcare Research and Quality, Rockville, MD; OptumInsight, 2014; The following 2014 CMS Limited Data Sets (LDS): Carrier, Denominator, Home Health Agency, Hospice, Outpatient, Skilled Nursing Facility; The Nielsen Company, LLC, 2016; Sg2 Analysis, 2016. 4 Lovald ST, Ong KL, Malkani AL, Lau EC, Schmier JK, Kurtz SM, Manley MT. Complications, Mortality, and Costs for Outpatient and Short-Stay Knee Arthroplasty Patients in Comparison to Standard-Stay Patients. J Arthroplasty 2014; 29: 510-5. 5 Arshi A, Leong NL, D'Oro A, Wang C, Buser Z, Wang JC, Jones KJ, Petrigliano FA, SooHoo NF. Outpatient Total Knee Arthroplasty is Associated with Higher Risk of Perioperative Complications. JBJS 2017; 99: 1978-86. 6 Luzzi AJ, Fleischman AN, Matthews CN, Crizer MP, Wilsman J, Parvizi J. The "Bundle Busters": Incidence and Costs of Postacute Complications Following Total Joint Arthroplasty. J Arthroplasty 2018; 33: 2734-9. 7 Rovinsky M, Looby S, Zacchigna L. The Shift to Outpatient TKA – What's the Big Deal? HFM 2018; July: 1-8. 8 National joint registry for England, Wales, Northern Ireland, and the Isle of Man (2017). National joint registry for England, Wales, Northern Ireland, and the Isle of Man Annual Report 2017 http://www.njrreports.org.uk/Portals/0/PDFdownloads/NJR%2014th%20Annual%20Report%202017.pdf

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