Q&A: Expert Insights on the Transition to Outpatient Total Shoulder Replacements

Dr. Lawrence Gulotta of Hospital for Special Surgery

With the Centers for Medicare & Medicaid Services (CMS) removing total shoulder replacements from the inpatient-only list in 2024 [see “Big Expectations,” sidebar below], the volume of outpatient shoulder surgeries has seen a significant increase that is expected to continue in the years to come.

This shift has created new opportunities for orthopedic facilities, particularly orthopedic and multispecialty ASCs, to enhance their service lines. While hips and knees remain the most common outpatient joint replacements, shoulders are increasing at a higher rate than those procedures.

Current, future trends

To explore the implications of this change and understand the latest advancements in outpatient shoulder replacements, we spoke with Lawrence V. Gulotta, MD, an orthopedic surgeon and leading expert in shoulder surgery from Hospital for Special Surgery (HSS) in New York City. Dr. Gulotta shared his insights on the transition, the multidisciplinary approach that total shoulder replacement requires and the future of shoulder arthroplasty in the outpatient setting.

Outpatient Surgery Magazine: Describe the process your facility went through to transition total shoulder replacements from inpatient to outpatient procedures.

Dr. Gulotta: Before COVID-19, 100% of our patients spent the night in the hospital, which was already a reduction from the two to three nights they used to stay a few years earlier. When the pandemic hit, no one wanted to be in the hospital if they could avoid it. This situation highlighted the need for an outpatient shoulder replacement program. Today, the majority — roughly 80% of our patients – go home the same day.

Transitioning to outpatient procedures required us to rethink and redesign various aspects of patient care. We implemented detailed preoperative education sessions to ensure patients are well-prepared for the procedure and recovery at home.

While the surgery itself remains relatively unchanged, it is the nursing, rehab and pain management that make the outpatient program successful. With that in mind, we coordinated closely with anesthesiologists to optimize pain management protocols, and our physical therapy team developed specific rehabilitation plans tailored for outpatient care. The surgeon may be the one to initiate the process of performing these procedures in an outpatient setting, but you need a solid anesthesia, nursing and physical therapy team to make it successful. It requires a team approach.

Dr. Gulotta: We use an algorithm that considers several factors, including pulmonary status, absence of active cardiac issues and controlled sleep apnea, among others. Sleep apnea is a common reason for keeping a patient under observation.

Social support is also critical. Patients need someone to be home with them post-surgery. If they lack this support, they may spend the night in the hospital. While around 80% of our patients go home the same day, the remaining 20% don’t meet this outpatient criteria or need to be kept under observation for a night before discharge.

We also assess the patient’s overall health, comorbidities and ability to follow postoperative care instructions. Patients who have well-managed chronic conditions and a robust support system at home are typically good candidates for outpatient surgery. This careful selection process helps ensure patient safety and successful recovery.

OSM: What specific tools, techniques and technologies have been most instrumental in making outpatient shoulder replacements feasible and efficient?

Dr. Gulotta: One of the biggest advances is in the planning. We use CT scans and computer programs to plan the size and position of the implant, making the surgery more reproducible and accurate. This also streamlines processes such as inventory management, turnover time and surgical efficiency.

In addition to surgical advancements, our approach to pain management has been instrumental in the success of outpatient shoulder replacements. We utilize a multimodal pain management strategy, which involves combining different types of medications such as acetaminophen, anti-inflammatories and a minimal amount of narcotics. This approach helps control pain effectively while reducing the reliance on any single medication, particularly narcotics.

We also administer a single-shot nerve block with additives to extend its duration, providing significant pain relief in the days immediately after surgery. It’s vital to explain to patients that while nerve blocks can provide long-lasting pain relief, they can also result in a temporary loss of arm function. While this may mean their arm is numb for a few days, the benefit of it being an upper extremity procedure is that the patient can walk around with their arm in a sling until the block wears off.

Finally, looking to the future, having a specific set of disposable instruments for each patient could further minimize inventory needs and enhance efficiency. That’s a direction I can see more facilities moving towards in the years to come.

HELPING HAND To stabilize and protect patients placed in the beach chair position, several positioning aids are needed.

OSM: How do you prepare patients preoperatively to ensure they have a successful outpatient experience, including pain management and recovery planning?

Dr. Gulotta: Setting expectations upfront is key. We provide extensive preoperative counseling, including webinars on what to expect on the day of surgery and during the perioperative period. We ensure patients meet with physical therapists before surgery to go over exercises and preparations, such as setting up their home for recovery. And as I mentioned, educating patients on what to expect with pain and how to manage it at home is a crucial component of our program, ensuring they are well prepared for a smooth recovery.

In addition to these measures, we also emphasize the importance of having the right equipment at home, such as wedges or recliners, to ensure comfortable sleeping arrangements. We also educate patients on the signs of potential complications and provide them with detailed instructions on who to contact if they have concerns after leaving the facility.

OSM: What does the postoperative care and follow-up process look like for your outpatient shoulder replacement patients, and how do you ensure they receive adequate support once they leave the facility?

Dr. Gulotta: Rigid oversight is essential. We call patients on day one to check in and answer any questions. Follow-up includes seeing a PA at two weeks post-op, and patients will then come in for an in-office visit at four weeks.

We also utilize a patient portal for communication, allowing patients to essentially email us with their questions or concerns. The benefit of this electronic communication is that they can send photos of things such as their incision, which is particularly helpful for monitoring their recovery.

In my experience, we’ve had only one readmission out of more than 1,000 outpatient replacements.
Lawrence V. Gulotta, MD

OSM: Can you share some of the outcomes you’ve observed in your outpatient shoulder replacement patients compared to those who undergo the procedure as inpatients?

Dr. Gulotta: Studies, including those by my colleague Quin Throckmorton, MD, at the Campbell Clinic in Tennessee, show that outpatient shoulder replacements can be done safely and with high satisfaction rates. In my experience, we’ve had only one readmission out of more than 1,000 outpatient replacements. We’ve seen that we can do this very safely and very efficiently.

These positive outcomes are a testament to the effectiveness of our multidisciplinary approach and the care we provide. Patients appreciate the ability to recover in the comfort of their own homes, which can significantly enhance their overall experience and satisfaction.

OSM: How do you see outpatient shoulder replacement evolving over the next five years, and what advancements are you most excited about?

Dr. Gulotta: I anticipate continued refinement of our postoperative monitoring programs and further advances in surgical planning and execution. Wearable technology could play a significant role in remote monitoring, allowing us to track patients’ recoveries more precisely. Patient-specific instrumentation and implants are also on the horizon, which will further minimize equipment needs and enhance the efficiency of outpatient procedures. Ultimately, it’s about optimizing every aspect of care to ensure the best outcomes for our patients. OSM

CPT CODES

Big Expectations for Total, Partial Shoulder Cases

When CMS reversed course in late 2023 and added total shoulder arthroplasty and partial shoulder arthroplasty (hemiarthroplasty) to the ASC-Covered Procedures List (ASC-CPL) starting on Jan. 1, 2024, it was welcome news to orthopedic facilities throughout the country.

Many providers envision the move giving a major boost to ASC business in the same way that CMS’ approval of total knees in 2019 and total hips in 2021 did. Of course, with new ASC procedures come new CPT codes. Here are the codes and their corresponding reimbursement amounts for 2024:

• CPT 23470 - partial shoulder arthroplasty: $9,307
• CPT 23472 - total shoulder arthroplasty: $14,003

—Outpatient Surgery Editors