Outpatient Total Knee Arthroplasty From a Stand-Alone Surgery Center: Safe as the Hospital?

Outpatient Total Joint Arthroplasty at an Ambulatory Surgical Center: An Analysis of Failure to Launch

BACKGROUND

There has been a tremendous increase in same-day discharge (SDD) following primary total joint arthroplasty (TJA). Although the concept of failure to launch (FTL) has been recently investigated in hospital settings, there is a paucity of data in the ambulatory surgical center (ASC) context. This study aimed to examine the incidence and underlying causes of FTL within an ASC at a major academic medical center.

METHODS

A retrospective review from 2021 to 2024 was performed on all patients who underwent same-day surgery at our ASC after intentional selection and medical optimization per institutional protocols. The demographic information, incidence and source of FTL, 90-day readmissions, and reoperations/revisions were recorded. There were 1,974 patients who underwent primary TJA at the ASC during the study.

RESULTS

There were nine patients who required direct hospital admission from the ASC (0.45%). This patient population had significantly increased American Society of Anesthesiologists score compared to patients who were discharged home. In addition, these patients had a significantly higher number of 90-day emergency department visits. Syncopal episodes were the most common reason for hospital admission from the ASC (66.7%), followed by nausea, seizures, and pain (all 11.1%). After review by attending orthopaedic surgeons and anesthesiologists, only two patients had potentially preventable medical causes for admission.

CONCLUSIONS

Approximately, 99.6% of patients had successful SDD at our ASC, underscoring the importance of proper preoperative screening. Only 0.45% of patients required hospital admission, primarily attributed to hypotension and syncopal events. Interestingly, only two patients in our cohort experienced a potentially preventable instance of FTL. It is crucial that additional efforts be aimed at identifying patients at risk and implementing treatment strategies to prevent postoperative hypotension and syncopal events that may further improve SDD and outcomes in outpatient TJA in the ASC setting.

"Outpatient Arthroplasty Risk Assessment" (OARA) Score for Same Day Outpatient Primary Total Joint Arthroplasty: A Multi-Center Study

BACKGROUND

The Outpatient Arthroplasty Risk Assessment (OARA) Score was developed to risk-stratify patients for safe same-day discharge outpatient total joint arthroplasty (TJA). It has demonstrated predictive ability for length of stay in primary TJA. However, there is minimal external validity of the original studies. This multicenter database study evaluated the risk assessment and predictive ability for same-day discharge of the OARA score and clinical outcomes following primary TJA.

METHODS

From 2017 to 2023, across 40 locations, 12,809 primary TJAs (4,656 hips, 8,153 knees) were identified. A total of 5,552 and 4,974 cases had length of stay, complication, and readmission data, respectively. Overall, 1,864 (34%) patients were discharged on the same day after primary TJA. Machine learning and statistical models evaluated the predictive ability of the OARA score on same-day discharge, readmission rates, and complications within 90 days. P-values ≤ 0.05 were considered statistically significant.

RESULTS

Patients who had an OARA Score < 60 and < 80 were ≥ 2.6 times more likely to be discharged on the same day of surgery. A lower OARA score was associated with proportionally fewer complications and readmissions (P ≤ 0.001). Complications and readmissions were 2.9 to 3.1 and 3.1 to 3.3 times more likely with OARA scores ≥ 60 and ≥ 80, respectively.

CONCLUSION

Study results demonstrate that patients who had lower OARA scores are more likely to be discharged the same day and have lower complication or readmission rates after primary TJA. These results from multiple centers across the United States further support the original studies and provide evidence for the continued use of the OARA score to help identify medically appropriate candidates for outpatient primary TJA.

The Predictability of the Outpatient Arthroplasty Risk Assessment Score on Clinical Outcomes Following Revision Total Joint Arthroplasty: A Preliminary Registry Analysis

BACKGROUND

The Outpatient Arthroplasty Risk Assessment (OARA) Score was developed to identify surgically appropriate patients for outpatient total joint arthroplasty (TJA). In addition, it has shown excellent predictive ability for length of stay (LOS) following primary TJA compared to other medical risk stratification systems. However, it has not been studied in the revision TJA (rTJA) patient population. This study evaluated the OARA score's ability to predict LOS and postoperative outcomes following rTJA.

METHODS

From 2017 to 2023, 366 rTJAs (116 hips, 250 knees) performed across 17 locations were analyzed. Statistical models evaluated the predictive ability of the OARA Score on same-day or next-day discharge, complications, and readmissions within 90 days. P-values ≤ 0.05 were considered statistically significant.

RESULTS

Overall, 156 (51%) rTJAs were discharged postoperatively on the same or the next day. A lower OARA score was a significant predictor of same- or next-day discharge, and proportionally fewer complications and readmissions (P ≤ 0.035). There were 71% of rTJAs discharged ≥ 2 days postoperatively when the OARA score was ≥ 113. Likewise, complications (19.6 versus 4.7%, P = 0.002) and readmissions (13.0 versus 3.4%, P = 0.016) were ≥ 4.2 (95% confidence interval, 1.4 to 12.8) times more likely when the OARA score was ≥ 113. For all models related to LOS, positive predictive values were great to excellent (range, 73 to 91%), while false positive rates were higher than ideal (range, 63 to 76%).

CONCLUSIONS

The study results demonstrate that a lower OARA score was predictive of same- or next-day discharge and fewer complications and readmissions following rTJA. As the burden of rTJA rises, future studies with higher sample sizes and accounting for revision etiology and the number of components revised should be conducted to further test the OARA Score's utility in the rTJA population.

Assessment of 90-Day Outcomes Following Total Joint Arthroplasty in Ambulatory Surgery Centers, Hospital Outpatient Departments, and Hospitals: A Michigan Arthroplasty Registry Collaborative Quality Initiative Analysis

Background

Total joint arthroplasty is shifting from hospitals to ambulatory surgery centers (ASCs) and hospital outpatient departments (HOPDs). A Michigan Arthroplasty Registry Quality Collaborative Initiative quality improvement project examined readmissions, emergency room (ER) visits, periprosthetic joint infection (PJI), fracture, and dislocation after primary total hip arthroplasty (THA) or total knee arthroplasty (TKA) across sites.

Methods

Primary TJAs between July 1, 2021, and June 30, 2022 (N = 41,696: 3910 ASC, 1,834 HOPD, and 35,952 hospital) were reviewed. Of 17,100 THAs, 9.5% (1,631) were at ASCs, 4.7% (798) at HOPDs, and 85.8% (14,671) at hospitals. Of 24,596 TKAs, 9.3% (2,279) were at ASC, 4.2% (1,036) at HOPDs, and 86.5% (21,281) at hospitals. Hospitals treated more elderly, women, non-White, obese, diabetics, smokers, and governmental insurance.

Results

For THAs, ASCs had the lowest 30-day (ASC 1%, HOPD 1.8%, hospital 3.4%, P < .001) and 90-day (ASC 1.7%, HOPD 3.4%, hospital 5.5%, P < .001) readmissions, 30-day ER visits (ASC 1.8%, HOPD 3.5%, hospital 5.3%, P < .001), and fractures (ASC 0.4%, HOPD 0.6%, hospital 1.2%, P < .001). Similar trends were observed for TKAs: 30-day readmissions (ASC 1.3%, HOPD 1.4%, hospital 3.1%, P < .001), 90-day readmissions (ASC 2.2%, HOPD 2.3%, hospital 5.2%, P < .001), and 30-day ER visits (ASC 3%, HOPD 6.5%, hospital 6.4%, P < .001). PJI (THA: P = .1, TKA: P = .6) and dislocation rates (P = .5) were similar across sites.

Conclusions

Patients receiving primary total joint arthroplasty at an ASC had the least postoperative hospital-based care despite similar rates of PJI and dislocation.

Optimizing Operating Room Efficiency for Primary Hip and Knee Arthroplasty Using Performance Benchmarks

Background

With increasing demand for total hip arthroplasty (THA) and total knee arthroplasty (TKA), maximizing operating room (OR) efficiency is critical. This paper sought to examine the implementation of time benchmarks when performing primary TKA and THA. We hypothesized that implementing benchmarks would improve efficiency and the number of joints performed per day.

Methods

Two hundred ninety-five patients from 59 OR days were reviewed. All surgeries were performed as outpatients and included 160 females and 135 males; 161 TKA and 134 THA; mean age, 66.1; mean body mass index, 28.6 kg/m2; American Society of Anesthesia, 2. Time points, demographics, and adverse events were recorded. Benchmarks to complete 4 joints in 8 h were: anesthesia preparation time (APT) of <11 min, procedure time of <72 min, anesthesia finish time (AFT) of <21 min, and turnover of <22 min.

Results

The percentage of cases meeting individual benchmarks for APT was 50.17%; procedure time was 95.25%; AFT was 99.67%; turnover was 65.25%. The means were: APT 11:00 min, Surgical Prep Time 9:00 min, procedure time 55:00 min, AFT 3:00 min, and turnover 19:00 min. Overall, 98.3% (58/59) of ORs had 4 cases completed within 8 h and 52.5% (31/59) had 5 cases within 8 h. Age, body mass index, and consecutive laterality of surgery were determined to affect the likelihood of meeting benchmarks for case time, APT, and turnover.

Conclusions

Establishing time benchmarks permitted the introduction of 5 joint days within an 8-h OR without increasing resource utilization. Factors that influence OR efficiency for high-volume primary hip and knee replacements were identified.

Outpatient Total Joint Arthroplasty in the "Unhealthy": Staying Safe Using Institutional Protocols

BACKGROUND

Recent expansion in the indications for outpatient total joint arthroplasty has led to debates over patient selection. The purpose of this study was to compare early clinical outcomes and complications of same-day discharge (SDD) hip and knee arthroplasties from a high-volume institution based on the American Society of Anesthesiologists (ASA) physical status classification.

METHODS

Prospectively collected data were reviewed for all SDD primary joint arthroplasties between January 2013 and August 2023. There were 8 surgeons who performed 7,258 cases at hospital outpatient (n = 4,288) or ambulatory surgery centers (n = 2,970). This included 3,239 total hip arthroplasties, 1,503 total knee arthroplasties, and 2,516 unicompartmental knee arthroplasties. The ASA 1 group comprised 506 subjects, compared to 5,005 for ASA 2 and 1,736 for ASA 3. The primary outcomes included emergency department (ED) visits, readmissions, complications, and revisions within 24 hours and 90 days of surgery. The ASA 3 group was older (ASA 1 = 55 versus ASA 2 = 63 versus ASA 3 = 66 years; P < .01) and had a higher body mass index (ASA 1 = 25.4 versus ASA 2 = 28.5 versus ASA 3 = 32.7; P < .01).

RESULTS

There were no differences between ASA groups in joint-related ED visits, readmissions, and complications within 24 h and 90 days of surgery (P > .05). Subjects in the ASA 3 group experienced greater 90-day revisions compared to the other groups (ASA 1 = 1 of 506, 0.2% versus ASA 2 = 15 of 5,005, 0.3% versus ASA 3 = 15 of 1,736, 0.9%; P = .01). Regarding systemic events, ASA 1 subjects experienced significantly greater 24-hour complications (8 of 506, 1.6%) and ED visits (5 of 506, 1.0%), and the ASA 3 subjects had a higher incidence of 90-day readmissions (19 of 1,736, 1.1%) compared to the other groups (P < .05). Within 24 hours of discharge, urinary retention and syncope were the most frequent complications that required additional health care utilization.

CONCLUSIONS

Medically optimized patients categorized as ASA 3 can safely undergo SDD hip and knee arthroplasty without increased risk of 24-hour or 90-day complications. Patient preference for outpatient care, reliable social support, and independent functional status are imperative for a successful outpatient program.

The outpatient experience in unicompartmental knee arthroplasty: How to perform safely in the ambulatory surgery center

The number of outpatient unicompartmental knee arthroplasty (UKA) procedures has increased substantially over the last decade. The ambulatory surgery center (ASC) and hospital outpatient department provide a safe, cost-effective alternative with significant cost savings to the healthcare system. Advancements in technology and perioperative management strategies have expanded the number of eligible patients to optimize outcomes with a focus on safety. Therefore, this review will describe the safety, efficacy, economics, and perioperative protocols for performing UKA in an outpatient setting. Patient selection, risk factors, patient education and expectations, anesthesia, pain management strategies, and outcomes will be discussed.

Comparison of Patients Based on Their Self-Selected Discharge Pathway after Total Knee Arthroplasty at an Ambulatory Surgical Center

Outpatient total knee arthroplasty (TKA) is being performed more frequently in ambulatory surgical centers (ASCs) to decrease the cost of care. Discharge pathways include 23-hour observation (OBSERVATION) or same-day discharge home (HOME), which differ in postoperative medical supervision. Few studies allow patients to self-select their discharge pathway. This study compared patient variables between self-selected OBSERVATION or HOME discharge after TKA at an ASC. We hypothesized that age, sex, and distance lived from the ASC would differ between discharge pathways. Clinical and patient-reported outcomes were explored.A chart review identified 130 patients with TKA at an ASC between November 2017 and December 2019. Patients self-selected OBSERVATION or HOME during a preoperative physician visit. Patient variables obtained from the electronic medical record were age, sex, race/ethnicity, marital status, body mass index, diabetic status, American Society of Anesthesiologists (ASA) class, distance lived from the ASC, anesthesia type, procedure time, and time in the postanesthesia recovery unit. Clinical outcomes (knee range of motion, infection rate, and reoperation rate) and patient-reported outcomes (Knee Injury and Osteoarthritis Outcome Score, Joint Replacement [KOOS, JR]; Oxford Knee Score [OKS]) were collected at either 6 or 12 weeks postsurgery. Variables were compared between groups.Pathway selection was n = 70 OBSERVATION and n = 60 HOME, and all patients completed their self-selected discharge pathway. Age and proportion of females were significantly higher in OBSERVATION than in HOME (61.3 ± 3.5 vs. 58.5 ± 5.4 years, 85.7 vs. 65.0%, respectively; p < 0.05). Distance lived from the ASC tended to be greater in OBSERVATION than HOME (22.1 ± 24.6 vs. 15.3 ± 10.1 miles, p = 0.056). Across groups, clinical outcomes were favorable (i.e., >88% met the 6-week knee flexion milestone, 1.9% infection rate, and 3.1% manipulation under anesthesia), and the preoperative to 12-week postoperative change in KOOS, JR and OKS scores met the minimal clinically important difference.Older age, female sex, and farther distance lived from the ASC may influence patients to select OBSERVATION over HOME discharge following TKA at an ASC. No robust differences were found in early outcomes.

Advanced Concepts in Outpatient Joint Arthroplasty

As the adoption and utilization of outpatient total joint arthroplasty continues to grow, key developments have enabled surgeons to safely and effectively perform these surgeries while increasing patient satisfaction and operating room efficiency. Here, the authors will discuss the evidence-based principles that have guided this paradigm shift in joint arthroplasty surgery, as well as practical methods for selecting appropriate candidates and optimizing perioperative care. There will be 5 core efficiency principles reviewed that can be used to improve organizational management, streamline workflow, and overcome barriers in the ambulatory surgery center. Finally, future directions in outpatient surgery at the ASC, including the merits of implementing robot assistance and computer navigation, as well as expanding indications for revision surgeries, will be debated.

The Impact of Bundled Payment Initiatives in Orthopedic Surgery Access to Care: Cherry Picking and Lemon Dropping

This editorial explores the impact of bundled payment initiatives, specifically in the context of orthopedic surgery, on access to care. We examine the phenomenon of "cherry picking" healthier patients and "lemon dropping" higher-risk patients, potentially leading to disparities in access and healthcare outcomes. We discuss recent studies investigating these concerns and highlight the need for more in-depth research to better understand the groups these policies may marginalize. Policymakers are urged to consider measures to protect disadvantaged patients and ensure equitable access to care, aligning with the principles of equality and diversity in healthcare.