Are You Capitalizing on the Total Joints Boom?

Healthy patients fearful of COVID-19 exposure in a hospital are flocking to ambulatory surgery centers and specialty hospitals for their hip and knee replacements, creating an unprecedented two-fold spike in outpatient total joint replacement volume, according to Michael Ast, MD, orthopedic surgeon and chief medical innovation officer at Hospital for Special Surgery (HSS) in New York City. Dr. Ast estimates that freestanding ASCs set up for total joint surgeries are handling about half, and in some cases up to 80%, of joint replacement surgeries. This is in stark contrast to the more gradual increase in total joint procedures migrating to an ambulatory setting over the last 10 years — starting with around 5% of the total market in 2012 and increasing to around 35% by 2019. Dr. Ast predicts the current patient-driven spike in outpatient total joints will expand to other surgeries and drive the need for more freestanding specialized surgical facilities.

The original catalyst for outpatient total joints has been forward-thinking orthopedic surgeons like Dr. Ast who have paved the way with standardized care pathways offering rapid recovery, short-stay outpatient surgeries and lower costs compared to inpatient procedures. The effectiveness and efficiency of this economic approach has garnered significant attention from payers for some time, with Medicare approval for outpatient total joint replacements dating back to January 2020.

Anthony Mascioli, MD, an orthopedic surgeon at the multicenter Campbell Clinic in Memphis, Tenn., is recognized as a pioneer in outpatient total joint surgery. He helped refine surgical technique, establish standardized care pathways and develop a proven algorithm for patient selection to make these cases successful in an ambulatory setting. Dr. Mascioli and his practice colleagues also worked to share outcome measures for these procedures through the National Quality Forum and even worked directly with payers, starting in 2015, to establish the first outpatient Diagnosis Related Groups (DRGs) for total knee and total hip replacements.

With patient demand high, surgical technique and standardized care pathways established, and payer reimbursement steadily aligning, the volume of total joint surgeries in the ambulatory setting will likely only continue to increase, and facilities need to be ready to capitalize on the surge.

As freestanding surgery centers across the country work to wrap their arms around this total joints boom, we asked Dr. Mascioli and Dr. Ast where leaders should focus their efforts. Both surgeons stressed the importance of looking to the literature for published results to build off from, especially for examples of patient care and operational success in total joints performed specifically in a freestanding ambulatory setting. Here’s a short list of areas they recommend focusing on that are backed by evidence and experience.

• Select the right patients. Dr. Mascioli recommends following his practice’s published patient selection algorithm, with strict adherence during the first couple years after launching an ASC-based total joints program. The algorithm outlines appropriate patients based on several factors, including an evaluation with the surgery center anesthesiologist to confirm the patient meets the American Society of Anesthesiologists (ASA) guidelines for surgical patients (patients with ASA IV are excluded from selection). A patient’s medical history and preoperative testing for electrocardiography, comprehensive metabolic panels and complete blood counts must be in normal, healthy ranges. Patients with certain comorbidities such as obstructive sleep apnea, body mass index greater than 35 kg/m2 and hypertension are excluded. (See the complete algorithm in Toy et al study in the sidebar.)

With any staffing approach, training is critical to get staff up to speed quickly.
— Michael Ast, MD

• Standardize clinical pathways. Look to published research from established, successful outpatient total joint centers for strategies on multimodal anesthesia in total hip, knee and shoulder surgeries, recommends Dr. Mascioli. For example, his patients undergoing total knee arthroplasty are given nerve blocks (peripheral blocks in the preoperative area and spinal blocks in the OR); perioperative intravenous antibiotics; and preoperative and intraoperative applications of chlorhexidine. To address blood management, all patients receive intravenous tranexamic acid intraoperatively, unless contraindicated, followed by topical tranexamic acid. Pain management regimens may also include pericapsular injection of liposomal bupivacaine, nonsteroidal anti-inflammatory drugs, gabapentin, tramadol, acetaminophen and oxycodone on an as-needed basis, as he described in a 2021 study by Mascioli and others in Journal of the American Academy of Orthopaedic Surgeons.  “The longer-acting local analgesics for appropriate patients can encourage mobility in the postoperative acute phase,” says Dr. Mascioli.

Dr. Ast also recommends a strict adherence to standardized clinical pathways for outpatient total hip and knee arthroplasty. While he stresses that the specifics of all pathways require targeted education and coordination, he says the primary focus should be placed on managing these three types of pathways:

Blood management: A protocol should include tranexamic acid and exclude patients with anemia.

Fluid management: If using regional anesthesia, hydrate two hours prior to surgery, hydrate during surgery and rehydrate after surgery to avoid dizziness for early postoperative ambulation.

Pain management: Focus on multimodal pain management and avoid narcotics.

• Build collaborative teams. Drs. Ast and Mascioli stress the value of having a dedicated team to execute standardized clinical care, particularly surgeons with a solid record of excellent surgical technique. 

Also, because staffing is a challenge right now in any surgery setting, the surgeons believe this area is likely the greatest challenge a surgery center will face in preparing for total joints cases. “It would not be prudent to start total joint surgeries with limited staff,” says Dr. Ast. “If that will be the case, consider a flexible staffing model.” For larger conglomerate ambulatory surgery groups, this flexibility can mean sharing staff between facilities. And if you’re not part of such an arrangement? Some smaller surgery centers are reaching out to local hospitals and bringing in per diem total joint or spine staff. “With any staffing approach, training is key to get staff up to speed quickly,” says Dr. Ast. “Centers are getting creative with training, too, such as by leveraging virtual training technology.”

• Prepare your patients. Once Dr. Mascioli’s patients are approved through the selection process, they complete an educational preoperative total joint class with physical therapy to understand their own role in recovery. 

“Identifying those patients on the front end that can do it, telling them what will transpire, and helping them understand we are all on the same team sets an expectation with the patient up front,” Dr. Mascioli notes. “From there it is up to me and my team to deliver that expectation through our predetermined approach and watch it bear fruit — our research shows it happens,” Dr. Mascioli says. (See the 2021 Mascioli et al study in the sidebar for outcomes data.)

• Make nimble capital purchases. As surgical facility leaders work to retrofit existing spaces or build new surgery centers, they need to be agile and consider various creative avenues to meet their needs, says Dr. Ast. 

In some cases, the need for additional capital may be achieved by partnering with a surgery center management company or other source 
of outside capital. 

For existing freestanding ASCs with increased volume in total joints, being nimble can simply involve strategizing for equipment, instruments, turnover and navigating patient throughput.

Dr. Ast suggests investing in a larger sterilizer and some type of patient engagement platform, which can deliver a personalized level of care to navigate the patient journey, while also helping the center monitor case turnover, staffing and equipment. “You have to understand the logistics of purchasing and managing instruments such as mallets and drills, as well as handling implants, because these things aren’t normally kept on-site at an ambulatory surgery center,” says Dr. Ast. “Once you understand the infrastructure needed, you realize it can cost upwards of $100,000 to start up a total joints program.” OSM