Value-based reimbursement and alternative payment models are putting increased pressure on the profitability of joint replacement procedures. Although same-day discharge is not a common part of these programs yet, according to James D. Slover, MD, the new payment paradigm will favor ambulatory surgery in the future.
At the 2017 Interdisciplinary Conference on Orthopedic Value-Based Care, Dr. Slover detailed best practices for outpatient joint replacements, which are expected to increase by 200% in the next decade (www.sg2.com/?health-care-intelligence-blog/?2016/?10/?prepared-shift-outpatient-total-knee-replacement/?).
“The transition to more outpatient procedures won’t happen overnight,” said Dr. Slover, an orthopedic surgeon at NYU Langone Medical Center, in New York City.
“It will require careful preparation—investing time to develop protocols and processes involving all members of the care team—to ensure a safe experience for patients. However, if we do this safely and efficiently while preserving quality, we can maintain a positive margin in this alternative payment environment.”
As Dr. Slover reported, since 2014, several hundred same-day total hip arthroplasties have been performed at NYU Langone Medical Center, and in early 2016, the center began same-day discharge for total knee and total shoulder arthroplasties, as well.
“We pursued this strategy cautiously and gradually, starting with select physician leaders who had reliably demonstrated discharge of patients in one day,” he explained. “Physicians need to be very involved in the process because it requires a lot of work outside the hospital beforehand.”
The biggest component, however, may be the patients themselves, who must be healthy and motivated for same-day surgery to be successful. As Dr. Slover indicated, patients must meet the following medical inclusion criteria to be considered:
- no active cardiac arrhythmia;
- no chronic anticoagulation medications;
- no moderate to severe obstructive sleep apnea;
- no medical comorbidities, such as chronic obstructive pulmonary disease or cardiac disease;
- a hemoglobin level of at least 12 g/dL; and
- a body mass index less than 40 kg/m2.
“In addition to these physiological requirements,” Dr. Slover said, “patients must be in full agreement. You’re not going to do well trying to convince them to do this.”
Nevertheless, for patients who do attempt same-day discharge, reinforcing expectations is critical.
“Patients need to know that this is a normal thing,” he added. “They need to be reminded that it’s not unsafe or experimental, and that appropriate support mechanisms have been put in place to do this successfully.”
Same-day discharge patients require a “coach,” a care companion willing to be with them on the day of surgery and spend the first night with them at home. In addition, both patient and coach must attend a preoperative education, or “prehab,” session, in which care management, pain control, deep vein thrombosis prophylaxis and assistive device training are discussed.
“Our pre-op protocol has been a major part of our success,” Dr. Slover said. “Patients need to recognize that arrangements have been made and that they will receive the care they need. The first time they’re hearing these instructions should not be on the afternoon after surgery.”
As Dr. Slover reported, preanesthesia medication includes 50 mg of pregabalin (Lyrica, Pfizer) by mouth; 200 mg of celecoxib by mouth; 1 g of IV acetaminophen; 25 mg of bethanechol by mouth (for men); 10 mg of IV dexamethasone; and 10 mg of IV metoclopramide.
For patients with a history of motion sickness, he added, use of a 1.5-mg scopolamine patch should be considered.
“We’re constantly trying to tweak this protocol, but the important message is that partners are needed across the whole continuum of care,” Dr. Slover said. “You’re not going to just insert this into the system as normal. You have to find champions in surgery, anesthesia and nursing, and work together to develop this pathway and protocol.”
During surgery, Dr. Slover and his colleagues rely on a short-acting spinal anesthetic—bupivacaine and chloroprocaine—and avoid use of a narcotic in a spinal block.
“These can’t be complex procedures,” he explained. “It’s important to pick patients where surgery is going to go well and where surgical trauma can be relatively minimal.”
Finally, in the postoperative period, Dr. Slover advised limiting narcotics and use of patient-controlled analgesia.
“We want patients to be comfortable and on a regimen that they’re going to use at home so that they know they can control their pain adequately,” he said.
This phase includes 1 g of acetaminophen by mouth; 5 mg of oxycodone by mouth for discomfort at a pain rating scale of 1 to 3; and 10 mg of oxycodone for pain rated 4 to 10.
“Go slow, pick the right patients, educate them, verify that infrastructure is in place, and make sure that all team members are dedicated to the process,” Dr. Slover concluded.
Mitchell H. Marshall, MD, chief of anesthesiology at NYU Langone Hospital for Joint Diseases, and his colleague Milad Nazemzadeh, MD, clinical associate professor of anesthesiology, helped implement the same-day surgery protocol, which emphasizes short-acting spinal anesthesia and a multimodal pain management approach that enables very early postoperative ambulation.
“Anesthesiologists are an integral part of the program,” Dr. Marshall said. “We were very happy to get on board and work to make sure that we developed an efficient and safe protocol that would serve the needs of the patient, the surgeon and the [anesthesiologist] as well.”
“We’ve come a long way in the last two years, working with the surgeons,” Dr. Nazemzadeh said. “Now almost every total joint is a candidate for same-day discharge.”
“At some point, like the four-minute mile, you reach a point where progress is only incremental,” Dr. Marshall added, “but we always think there’s room for optimization.”