If you want to run a successful outpatient total joint program, identify patients who can withstand the physical rigors of the procedures and show up believing they'll be ready to leave your facility soon after surgery ends. "Patient selection encompasses everything — motivation, health history, home support, insurance," says James T. Caillouette, MD, an orthopedic surgeon at Newport Orthopedic Institute in Newport Beach, Calif. He and other experts recommended you assess the following key factors when selecting patients for same-day arthroplasty.

Deal-breakers
Understanding who is not a suitable candidate for having procedures done in the outpatient setting will help you focus on those who are, says Gwo-Chin Lee, MD, an associate professor of orthopedic surgery at the Presbyterian Medical Center of Philadelphia and fellowship director of adult reconstruction at the University of Pennsylvania.

Dr. Lee conducted a recent study that looked at complication rates following total joint procedures. He found that about 7% of patients undergoing a total knee or total hip replacement — including both short-stay patients and inpatients — suffered from complications that required visits to the ER or a doctor's office. Most of the patients who developed serious complications had cardiopulmonary problems (osmag.net/QKVg2x).

From his study results, he came up with 5 conditions that should disqualify a patient for same-day joint replacement:

• congestive heart failure
• cirrhosis of the liver
• coronary heart disease
• coronary artery disease
• chronic COPD

Dr. Caillouette begins the patient selection process by considering patients' ASA scores. "I don't take patients as outpatients if they don't have a 1 or 2 ASA score," he says. "Any history of cardiopulmonary problems is also a deal-breaker."

It's also crucial to make sure patients want to go home the same day of surgery. "Some patients come in with the expectation that they're going to stay in the hospital for a number of days," says Dr. Lee. "Those patients are obviously not good candidates. A patient's attitude has very little to do with the medical side of patient selection, but it's an important, if not the most important, thing."

Activity level and BMI
There's no hard-and-fast rule about a BMI threshold for joint replacement. "Obesity in this country is a problem," says Richard G. Buch, MD, orthopedic surgeon at The Dallas (Texas) Limb Restoration Center. "That makes it hard to use BMI as a selection tool. By national standards, anyone who is over 30 BMI is considered obese, but that would eliminate nearly half of the entire population."

Instead, rely on a combination of BMI and activity level to make the final decision. "Typically if the BMI is over 35, I'm less likely to choose them, and especially if it's over 40," says Dr. Buch. "But it depends on the patient. Someone might be bigger, but also very active."

"Quite frankly, I look for a lower weight," adds Dr. Caillouette. "I typically have a BMI cutoff of 36. Now, that doesn't mean it's impossible to operate on patients with higher BMIs — I've performed procedures on patients who are 6'8 and 300 pounds in an ASC. But they were former professional athletes who were very healthy overall."

Gabrielle White, RN, CASC, executive director of ambulatory services and network development at the Orthopedic Surgery Center of Orange County in Newport Beach, Calif., notes that her center's guidelines call for a BMI upper limit of 32 for total joint replacement. "Though the patient could be a 33 or a 34, and just carry their weight in a certain area or be very muscular," she adds. In these borderline cases, the center trusts the surgeons and anesthetists to make the final call.

Comorbidities
As a growing number of younger individuals require total joint replacement, the population of healthy, active patients is plentiful. That can make the patient selection process easy, says Dr. Buch.

"Someone in their 50s who hasn't had a heart attack, isn't diabetic and doesn't smoke, will usually need only a lab test to ensure everything is OK before surgery," he says. "But patients 60 and older should, in addition to standard lab-work, be reviewed by their internist to check on the condition of the kidneys, lungs and heart."

But even patients without perfect health can be eligible. Ms. White says ASA 2 patients — those with controlled systemic diseases — can be good candidates, depending on how well they manage their conditions.

Consider diabetic patients. Dr. Caillouette notes that he'll perform outpatient arthroplasty on diabetic patients as long as their hemoglobin A1c levels are below 7%, which means their blood sugar is adequately controlled. Even if the patient's diabetes is controlled, you still want to schedule surgery early in the day so they aren't NPO for a long time and at risk of getting dangerously low blood sugar. "I do my total joints in the morning, so it usually doesn't present as much of a problem," says Dr. Caillouette.

Ensuring patients are suitable for surgery also requires more thorough pre-op testing. Ms. White notes that in addition to the center's standard pre-admission protocol, patients undergoing joint replacement must get tested for MRSA within 30 days of surgery. "Surgeons won't proceed if they test positive," she notes. "They reschedule it until the patient is decolonized and cleared."

Though exceedingly rare, Ms. White also says the center has a plan in place if there's ever a conflict with the surgeon over whether a patient is "relatively healthy" enough for the procedure. "We consult with our anesthesia medical director on anything that's out of our comfort zone," she says.

READY AND WILLING Patients must be healthy enough to recover quickly from complex procedures.

Home support
If a patient is 50 years old with a BMI of 29 and no comorbidities, but he lives alone, could he still be a candidate? Not likely. "Patients need adequate social support if they're going home the day of surgery," says Dr. Lee. "You still need a family structure or social network that's conducive to recovery in addition to having living quarters that don't put the patient at unnecessary risk."

You should establish — by simply asking or by visiting the home — that patients will be returning to a safe space. Some facilities even take the extra step to send physical therapists to the home a few days before surgery to check the number of stairs and clear any potential tripping hazards. "If your living quarters require you go up 20 flights of stairs, being discharged to home isn't going to happen," says Dr. Lee.

Willing insurers
One quick way to narrow down patients has nothing to do with their overall health or attitude. "They've got to be under 65 typically," says Dr. Caillouette. "And that's because Medicare doesn't yet pay for total joint procedures done in the outpatient setting."

In fact, one of the reasons same-day joint replacement isn't more widespread is due to CMS's hesitance to reimburse the procedure. "It can take a while for insurers to realize that they're saving money because patients are out faster and return home," says Dr. Buch. "There's been pushback against it, especially from Medicare, because they want them to remain hospitalized for 2 days."

Private payers, though, are opening up to the idea of outpatient total joints, thanks to its cost-savings and increased patient satisfaction. Ms. White notes her center takes cash-paying patients and those using their employers' domestic medical travel plans. The center has also worked out contracts with several commercial HMO and PPO plans. Ms. White points out that many big name national insurers are starting to reimburse for same-day joints.

She says the key to promoting outpatient total joints to insurers is being transparent about exactly how your costs, patient satisfaction scores and complication rates compare to inpatient joint replacements. That's usually enough to pique their interest. OSM