Joint replacements increasingly move out of the hospital

Patient selection is a key criterion for success

A small but increasing number of orthopedic surgeons are providing total joint replacements on an outpatient basis, Harris Meyer writes for Modern Healthcare.

Total hip and knee replacements have traditionally been performed in an inpatient surgical unit. Patients usually stay in the hospital for several days after the procedure and then receive skilled nursing, rehabilitation, or home care.

Providers and patients generally thought that the pain, mobility, and infection risks associated with total joint replacements necessitated a days-long hospital stay. Further, CMS doesn't cover total joint replacements performed in outpatient settings—although observers predict that may change in the years to come.

Moving toward outpatient

But increasingly, outpatient total joint replacements are becoming feasible due to advances in anesthesia, pain control, and surgical techniques.

An Advisory Board Company analysis of 354 hospitals found that 23 percent of hospitals reported performing some outpatient knee replacements, while 7 percent performed some outpatient hip replacements.

"More hospitals are starting to move joint replacement into outpatient settings to compete with (freestanding) ambulatory surgery centers," says Shruti Tiwari, a senior consultant at the Advisory Board.

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Surgeons shifting toward outpatient procedures say very few of their patients need skilled nursing, rehabilitation, or home care following the replacements. Some surgeons send patients home within hours, while others ask patients to spend the night in the surgery center or hospital during a 23-hour stay.

According to Modern Healthcare, interest in performing more outpatient total joint replacements is driven by factors including increased convenience, increased patient satisfaction, reduced costs, and reduced risk of hospital-acquired infections.

Financial implications

Orthopedic surgeons say outpatient joint replacements cost roughly half as much as those performed as inpatient procedures. One reason is that surgeons receive lower reimbursements for outpatient joint replacements.

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According to Modern Healthcare, that means the shift toward outpatient total joint replacements could threaten hospitals' finances. For example, in 2014 the federal government paid about $50,000 per hospitalization for hip or knee replacement—costing more than $7 billion for the year.

In addition, the usefulness of Medicare's bundled-payment initiative for inpatient joint replacements could come into question if CMS decides to cover outpatient replacements under Medicare and Medicaid.

"Why would we not encourage the migration to outpatient if the outcome is the same and the cost is lower?" says Jeff Goldsmith, a national adviser to Navigant Healthcare. "Why preserve the (inpatient bundling) program if the whole point is to save money for Medicare?"

Some experts believe insurers increasingly will accept the shift to outpatient care in response to patient demand.

Michael Dandorph, COO at Rush University Medical Center, predicts that as much as a quarter of all joint replacements would be conducted in outpatient settings if Medicare were to cover the procedures at such facilities (Meyer, Modern Healthcare, 6/4).

Keys to successful outcomes in outpatient joint procedures

Tiwari tells the Daily Briefing that a key variable in shifting some joint replacements to outpatient settings while avoiding complications is careful patient selection. Specifically, she says, the Advisory Board's research shows that the strongest candidates for outpatient joint replacement surgery:

  • Have no or minimal co-morbidities such as diabetes, hypertension, or obstructive sleep apnea;
  • Have a lower-range Body Mass Index; and
  • Have a caregiver at home to assist with recovery.

Tiwari notes that each provider may have unique selection criteria, but that "they ultimately rely upon the same principle: patients should be in good overall health to reduce the risk of life-threatening complications both intra-and post-operatively."  

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