Who, where, why, and the data behind it. Outpatient Joints Who, where, why, and the data behind it.

Disclosure slide I don’t do outpatient total joints I don’t have any other financial disclosures

Back Ground 700,000 Total knee arthroplasties (TKA’s) are performed in the US every year 325,000 Total Hip arthroplasties (THA’s) are performed every year Traditionally there was a long inpatient stay associated with either procedure Over the last 20 years there has been a trend towards shorter and shorter stays This has inevitably lead to what was once considered “pushing the envelope”, but is now quite commonplace: OUTPATIENT TOTAL JOINTS

WHY has there been this shift? 1) We orthopods don’t like rounding 2) Advances in multimodal pain control make this possible. 3) There is a SIGNIFICANT cost savings associated with outpatient procedures 4) As surgeons, we have much more control over the environment in an outpatient setting (can choose our staff, anesthesia methods, etc) The first one is probably the biggest one Multimodal pain control is definitely becoming a hot topic, and we continue to work to get pain better and better controlled while MINIMIZING narcotic usage Let’s just take total hips. If 25% of total hips were done on an outpatient basis, that would save 300 MILLION annually. The last point is something that also is a BIG deal, although might not seem like it. The Shift to Same-Day Outpatient Joint Arthroplasty: A Systematic ReviewJeffrey D. Hoffmann, MD a, Nicholas A. Kusnezov, MD a, John C. Dunn, MD a, Nicholas J. Zarkadis, DO a, *, Gens P. Goodman, DO a, Richard A. Berger, MD

THIS SEEMS KINDA CRAZY I agree. In residency, EVERYONE stayed until post operative day #3. That was what we did. It wasn’t even an OPTION to be discharged before that. Even if you were doing well.

What are the national trends on this AAHKS numbers: Majority of surgeons are moving to do at least 10-25% of their joints as outpatients. This is a rapid increase from the past in which almost no one was doing total joints The

AAHKS position statement Outpatient total joint arthroplasty can be performed, but there must be a robust system in place to optimize patient outcomes and minimize possible complications. Patient selection (on medical grounds) Patient education and expectation management (eg, preoperative “joint school”) Social support and environmental factors (family or professional outpatient support) Clinical and surgical team expertise Institution facility or surgery center factors (history of successful team work and an environment conducive to optimizing surgical outcomes) Evidence-based protocols and pathways for pain management, blood conservation, wound management, mobilization, and VTE prophylaxis. As of September 2018, AAHKS came out with a position statement on outpatient total joints based on the large number of surgeons now adopting this method. Medical optimization must be performed, patient education, the patient MUST have social support.

IS outpatient joint replacement safe? Studies have shown that outpatient total joint replacement has consistently shown: Similar readmission rates Similar medical complications (urinary retention, constipation requiring intervention, cardiac events, etc) Similar surgical complications (wound infections, intra-operative complications) Similar patient outcomes (range of motion, satisfaction, joint scores) When compared to inpatient total joint replacement when corrected for factors

Let’s look at the data. That guy was awesome.

Doing the majority of their patients as outpatients This was a crude study on their experience at Joint Implant Surgeons, but as your can see they had very little complications compared

At that time, 1% underwent outpatient procedure Meta-analysis looking at national registry data regarding inpatient vs outpatient joints At that time, 1% underwent outpatient procedure No difference in adverse events, although increase in DVT rates for inpatient procedures. They found certain patient factors had increased risk of post operative complications in outpatient procedures National database analysis Found that when analyzed together, no difference in adverse events between Outpatient TJA and inpatient TJA. However, inpatients had a higher rate of DVTs (maybe that’s because they were checked?) They found that certain factors were associated with increased risks in the outpatient procedure such as elevated BMI, IDDM, and age over 85. (WHO IS DOING OUTPATIENT JOINTS IN THESE PATIENTS ANYWAYS?)

Overall low risk of complications Systematic analysis of all studies done between 2010 and 2016 on outpatient TJA Overall low risk of complications No increased risk of readmission (1-2%) No increased risk of infection No increased risk of post operative medical comorbidities. This was actually a well done article. Between 2010 and 2016 there were 10 well done studies on outpatient TJA. This summarized all of them. Basically very low risk of badness happening.

National database study on inpatient vs outpatient joints reviewed between 2007-2015. This study showed: Higher rate of just about every complication possible Loosening DVT Explant Stiffness requiring manipulation Acute renal failure

Conclusion There are significant advantages to undergoing an outpatient total joint It is NOT indicated for everyone There is already near widespread adoption of outpatient joints across the US.