OUT IS IN Less invasive approaches, rigid patient selection and advances in pain management have made many procedures ideal for outpatient settings.

When Harbinder S. Chadha, MD, started his career in 1998, orthopedic surgery was mostly a hospital-based affair. Back then, a hip-arthroplasty patient would be admitted the night before the surgery, and then recuperate in the hospital for 5 to 14 days afterward. It was pretty much the same for an ACL repair.

My, how times have changed. Today, Dr. Chadha does about 150 total joint replacements per year. Patients arrive in the morning, have the surgery and, barring any complications, are back at home in their own beds later the same day.

Total joints are just one example of procedures that were once "inpatient only" but are now being done routinely in outpatient settings. He sees this steady migration as a classic example of providers simply giving consumers what they want.

"Patients have been driving this," says Dr. Chadha, who practices at the Otay Lakes Surgery Center in San Diego, Calif. "They wanted their independence in controlling their pain medication, they wanted their autonomy and they wanted their privacy. They knew they could gain all those by having us get them home quicker."

For David Shapiro, MD, a Tallahassee, Fla.-based anesthesiologist and past president of the Ambulatory Surgery Center Association, the procedures now being performed in outpatient facilities were "unimaginable" 20 or even 10 years ago. He credits seismic shifts in 3 distinct areas: less invasive approaches to surgery; more effective assessments of patients and their home-care situations; and advances in pain management.

"Patients have come to expect 100% perfection from their surgery, no matter where it's being performed," he says. "The care in outpatient facilities tends to be equal to inpatient or even better. We've also seen the rapid deployment of new drugs that are more potent, with a faster onset and offset, which means we can give deeper anesthesia without any lingering effects beyond the immediate post-operative period."

Patient satisfaction aside, Dr. Chadha believes surgery in outpatient settings has eased the burden on the U.S. healthcare system. This includes not only a reduction in costs associated with length of stay, but also a drop in expenses tied to treating surgical site infections. He cites his own facility's track record: a single ACL infection in more than a decade of operation.

Assuming an outpatient facility practices careful patient selection, has the right staffing and equipment, and can effectively manage the patient's post-operative pain and prevent nausea and vomiting, there's almost no end to the kinds of procedures that can — and will — be done in an outpatient setting. On the following pages, we explore 5 procedures that continue to gain steam in outpatient settings: bariatric surgery, hysterectomy, robotic prostatectomy, spinal surgery and total joint replacement.

UNCOMPLICATED Since opening in 2010, the Georgia Advanced Surgery Center for Women in Cartersville, Ga., has performed more than 800 consecutive hysterectomies without significant complications.

A study published in the December 2015 issue of the Journal of Minimally Invasive Gynecology (osmag.net/s7VdUE) changed the game for surgeons like Hugo D. Ribot Jr., MD, FACOG, ACGE. The study, authored by Barbara S. Levy, MD, FACOG, essentially showed Dr. Ribot how to address "the factors that would conspire to keep people in the hospital" — namely, pain control, nausea control and bladder management — as prelude to safely and reliably performing a vaginal hysterectomy in an outpatient setting.

Dr. Ribot, the managing partner of Cartersville (Ga.) OB/GYN Associates, had one thought after reviewing Dr. Levy's study: If she can do it, so can we.

As it turns out, he was right. Of the nearly 1,800 hysterectomy cases his practice completed from January 2006 through March 2017, nearly 99% of those patients went home the same day. The remaining 1% had pre-existing conditions that contraindicated outpatient surgery, he says. In May 2010, Dr. Ribot founded the Georgia Advanced Surgery Center for Women, an ambulatory facility in Cartersville, Ga., where he and his fellow surgeons perform every hysterectomy, unless a patient's insurance coverage dictates it must be done in a hospital. Since opening their ASC, they've performed more than 800 consecutive hysterectomies there without hospital transfers, conversions to open surgery, blood transfusions or significant complications.

"When we first started doing minimally invasive hysterectomy, it was 2 or 3 days in the hospital, and then it was an overnight stay," says Dr. Ribot. "I now need a good reason to keep someone in the hospital. One of the big concerns you hear from surgeons is: 'What if there's a post-operative hemorrhage and you have to rush back in to tie it off?' But if you're obsessive and meticulous about hemostasis, that's not been an issue."

His protocol for outpatient laparoscopic hysterectomy mirrors Dr. Levy's for vaginal hysterectomy. This includes pre- and post-operative interventions to prevent nausea and vomiting, as well as a preemptive local block — "an injection of a special cocktail of long-acting local anesthetic" into each uterosacral ligament, he says — prior to making the incision. For patients who are not candidates for vaginal hysterectomy, Dr. Ribot has adapted a method for delivering the paracervical block in laparoscopic cases, using a butterfly needle through a trocar.

Likewise, Dr. Ribot says managing the patient's expectations before, during and after the procedure is essential. Pre-operative counseling includes a discussion of at-home catheter care, as 30% to 50% of patients who undergo hysterectomy go home with a catheter because they can't empty their bladder by the time of discharge. To date, not a single patient has reported issues with subsequent catheter removal at home.

"This is stuff people should have been doing since 2006," he says. "If you're sticking to protocols like Barbara Levy's, there's certainly no technical reason you shouldn't be doing it now."

Besides the training and mentoring needed to master the surgery, Dr. Ribot suggests a standard endoscopic video tower, with a high-definition camera and a good fiber-optic light source; standard laparoscopic instruments such as graspers, needle holders and bipolar forceps; and an ultrasonic or radiofrequency/bipolar vessel sealer. Good optics may help, too. He says seeing the procedure unfold on a big, bright 4K screen would be "fantastic," but he doesn't believe it's necessary. Case in point: He's using 1080p surgical displays, and "our outcomes speak for themselves."

As for robotics-assisted hysterectomy, he says the awareness it has created has helped to improve uptake of minimally invasive hysterectomy. But it's cost-prohibitive for the ASC setting and adds to surgical time unnecessarily. He likens it to "using a Lamborghini to do something you could do with a Ford Focus."

— Bill Donahue

HIGH TECH New technology and instrumentation have enabled Dr. Chadha to perform outpatient total hip replacements with repeatable, predictable outcomes.

Total joints might be surgery's hottest and most in-demand specialty. Nearly a million patients undergo same-day knee and hip procedures in the United States each year, and that number is expected to triple by 2030.

While not every patient needs to have joints replaced in the hospital setting, some of the patients who want same-day joint replacement aren't candidates to have it done — despite the fact that patients who are seeking joint replacements nowadays are significantly younger and healthier.

J. Ryan Martin, MD, an orthopedic surgeon with OrthoCarolina in Matthews, N.C., does "maybe 5%" of his total knees on an outpatient basis, and in a hospital rather than in a surgical center. He expects that number to rise as he builds "a comfort level."

"Patients are asking for it, and I have a low threshold for keeping patients overnight," he says. "I think there's a psychic benefit to getting back in your own bed rather than the stigma of being in a hospital and getting woken up at 2 a.m. and 4 a.m. for vital signs."

In 2016, outpatient settings represented 15% of all primary hip and knee replacements, according to healthcare analytics firm Sg2. By 2026, outpatient is expected to outpace inpatient's share of volume, 51% to 49%. Last year CMS announced it would consider striking primary total knee replacement procedure from its "inpatient-only" list.

"Outpatient joint replacements are a significant cost savings to the system," says Harbinder S. Chadha, MD, an orthopedic surgeon with Otay Lakes Surgery Center in San Diego, Calif. "Comparing the hospital to the surgery center, it's about one-third of the cost, and that's why [insurers] are allowing it."

Dr. Chadha, who specializes in total hips, says new technology and instrumentation have enabled surgeons like him to perform total joint surgeries outside the hospital with repeatable, predictable outcomes. Besides changes in how the surgery is being performed, outpatient surgical facilities have also had to transform how they approach post-op pain control — opioid-sparing multimodal regimens are increasingly popular — and patient selection. Dr. Martin says surgeons and their staff now do "a lot more work" in terms of pre- and post-op planning. But not everyone is a suitable candidate.

"We as physicians need to stick to strict criteria, especially as our comfort level eases," says Dr. Martin, "because you don't want any complications when the patient is home."

An example: working with obese patients to optimize their weight before surgery, especially for total knees and total hips. Dr. Martin recommends drawing a line at a BMI of 40, and working with non-optimal patients to lose weight as a means of reducing the risk of surgical complications.

"We'll also want patients to come in for a pre-op physical therapy session so they know how to use a walker before the surgery," he says. "If they're just learning that after the surgery, when they're in pain, it could slow their rehabilitation."

— Bill Donahue

GO SLOW Dr. Gantwerker's advice to facilities considering adding spine to their service lines: Start slowly, and be on the lookout for hidden costs.

Most of the outpatient spinal surgeries being done at The Craniospinal Center of Los Angeles (Calif.) are along the minimally invasive lines of spinal decompressions and maybe cervical disc arthroplasty. But that's likely to change before too long, according to Brian R. Gantwerker, MD, the center's founder.

"Mostly, it's the non-instrumented procedures, but those will shift more toward fusions and artificial discs," he says. "Some facilities are already pushing the envelope with things like anterior and posterior lumbar fusion, but it's more often the procedures like lumbar discectomy and the implantation of some stabilization devices — those are driving the bus right now."

He says the No. 1 driver behind the increasing demand for outpatient spine is government cost-cutting measures aimed at trimming "out of control" healthcare costs. And he believes that focus is only going to intensify.

"The drive to save money is there," he says. "You're starting to see Medicare for outpatient spine. A lot of the taboos have lifted. The wave of the future is now reality."

Dr. Gantwerker believes it's the "fear factor" — liability concerns, in other words — that's keeping some surgical facilities out of the outpatient spine business. But he says the right equipment and a properly selected patient can mitigate the safety risk.

"The upside for reimbursements is really nice," he says. "For a spinal cord stimulator, you're talking $20,000 to $30,000, so you could make a nice profit."

To get a program off the ground, a surgical facility would need "basic spine instruments" — tools such as retractors, curettes and a neuro microscope, for starters. Intraoperative fluoroscopy would be a necessity, as well, so the facility would need to factor approximately $150,000 for the capital cost of a C-arm into the budget.

His parting words to outpatient facilities considering adding spine to their service lines: Manage patient expectations, develop protocols for pain control, and don't take on any procedure that makes you or your facility uncomfortable.

"Start slowly, maybe with microdiscectomy," he says. "And be aware of the hidden cost involved with things like neuro-monitoring, which is an important safety feature but can have an effect on your case costs."

— Bill Donahue

WISE CHOICE With good patient selection, bariatric surgery can be "safer to do than a gallbladder removal," says Dr. Uchal.

Some forms of bariatric surgery are tailor made for outpatient settings, says Miroslav Uchal, MD, FACS, FASMBS, director of bariatric surgery at St. Vincent's Medical Center in Jacksonville, Fla. Although the more intensive gastric bypass is best served as an inpatient procedure, the intra-gastric balloon and gastric banding surgery can be safely done outpatient. Also, Dr. Uchal can see scenarios in which the gastric sleeve could be an outpatient option.

He does, however, offer some important caveats. As a bariatric surgeon, even though you're using micro-instruments to make smaller incisions, controlling the patient's nausea and post-operative pain — without opioids, if at all possible — is essential. Also, you must have access to an IV infusion center nearby to prevent patients from getting behind on their fluids, which may contribute to kidney failure and other post-operative complications. His best piece of advice: Select patients carefully.

"If you have good patient selection, bariatric surgery can be safer to do than a gallbladder removal," he says. "Someone with a lower BMI might be a better candidate. Younger might be better. Female might be better."

There's a fine line between patients who are better for inpatient versus outpatient, he says. In general, those with a BMI of 40 and lower would be suitable for outpatient settings, while those who have a BMI of more than 40 would best be treated in a hospital. Also, obstructive sleep apnea would be a contraindication for outpatient surgery.

Compared to some other procedures, the need for pre- and post-operative education may be greater for patients undergoing bariatric surgery because of their struggles with food addiction. Dr. Uchal meets with patients multiple times, but he also prescribes structured bariatric education and membership in a support group.

— Bill Donahue

??? PAYING DIVIDENDS Dr. Mitchell says investing in a robotics system makes sense only if it brings new patients into the surgical facility or decreases patients' length of stay.

Robotics systems have been the target of criticism since they first found their way into ORs. "They're too expensive," they said. "They extend the duration of the surgery," they said. Don't tell that to Christopher R. Mitchell, MD, the director of robotic surgery at Christiana Care in Newark, Del.

"Historically, the pelvis is a hard location to operate in, and there's been a reluctance to do prostate surgery because of the side effects; erectile problems and urinary problems have been fairly common," he says. "Those issues have been improved upon. Robotics systems have opened the frontier for the increased use of surgery in treating prostate cancer, and they're helping patients recover faster and get back into the routine."

He's quick to point out that robotic prostatectomy is not yet a 100% outpatient procedure. In fact, he says, only "healthy, motivated patients" go home the same day. Most people stay in the hospital for one night of observation.

"There's still a lot of moving parts — removing the prostate, reconnecting the bladder and the urethra," he says. "Also, patients will have a Foley catheter for 7 days, and so they are often overwhelmed and there's a lot of education that has to take place."

Of course, adding this surgery to your service lines does require substantial investments of time, training and capital. He puts the financial investment at $1 million to $2 million per robot, "and each new permutation costs a little more," he says.

"It's not for everyone, but there's a strong market force behind it," he says. "Some patients think that it must be better if it's being done robotically, but that depends on the surgeon. The robot doesn't do anything autonomously; every millimeter of movement is under the surgeon's direction, so you really have to know what you're doing."

Christiana Care has 4 robotic surgical systems shared by multiple service lines. The health system has standardized a credentialing pathway, complete with training sessions. By the time the surgeon is doing a robotic prostatectomy on a live patient, he or she has taken all the necessary steps to be proficient with the system. Even then, the first surgery is done with a proctor, and an in-house expert observes several cases after that.

"Every surgery is different; it's not like flying an airplane, where 95% is the same and you have small degrees of variation," he says. "There's a learning curve. You have to be able to think 3-dimensionally, and you have to learn the visual cues and become a master at manipulating the robot."

From a business perspective — because of the capital costs, the ongoing maintenance costs and the fact that a robotic prostatectomy is not reimbursed at a higher rate — there are only 2 ways investing in a robotics system makes sense, says Dr. Mitchell: bringing new patients into the facility; or decreasing patients' length of stay. As far he's concerned, robotics systems have helped Christiana Care do both and then some.

— Bill Donahue