JOINT EFFORT Knee replacements can be done in outpatient facilities with a perfectly executed multidisciplinary team approach.

Outpatient knee replacement is one of surgery's hottest trends, but questions persist about how to best prepare patients for same-day discharge. Is robotics necessary? Do you really need to work with vendor reps? Is regional anesthesia a better option than inhalational? Whether you're thinking about adding outpatient knees or you already host the procedures, read on to find out what experts say about those key considerations.

Weighing in on robotics
Orthopedic surgeon Kevin Stone, MD, of the Stone Clinic in San Francisco, Calif., has been using robotics to perform partial knee replacements for the past 3 years. "I had been doing them without the robot for 25 years, but the accuracy was never quite high enough to place the implant perfectly every time," he says. "The robotic device provides a much higher level of confidence."

A computerized model of the joint's anatomy is built from a pre-op CT scan of the knee. The computer then plans the accurate placement of the implant by adjusting its position, rotation and alignment. On the day of surgery, surgeons place pins containing arrays in the femur and tibia that tell the robot where the knee is in space and match it to the computer model. "We're then able to place a burr that removes only the worn part of the knee we're resurfacing and place the implant in that spot," explains Dr. Stone.

Orthopedic surgeon and joint replacement specialist Sharat Kusuma, MD, MBA, recognizes the benefits offered by robotics and believes the technology can be a game-changer for low-volume surgeons. The current surgical consultant and former director of adult reconstruction at the Grant Medical Center in Columbus, Ohio, has colleagues who knew they weren't skilled at partial knees, but wanted to offer patients a needed service and improved outcomes. They got robotics programs up and running and became prolific. "That's the story you want to hear," says Dr. Kusuma. "You don't want to hear about the hospital that invested in robotics just to market the technology to patients. That's healthcare dollars not well spent."

Robotics is expensive and may not be cost effective, especially for high-volume, skilled surgeons, says Dr. Kusuma. He says robotics provides improved accuracy for surgeons, but there's nothing about the technology that enables outpatient surgery. That requires excellent surgical technique and excellent perioperative management — picking patients who are healthy enough for the procedure, treating their pain effectively and getting them in the mindset of going home on the day of the surgery.

Dr. Kusuma wants healthcare resources invested in low-volume surgeons who get poor outcomes, the docs who would benefit the most from the enhanced accuracy offered by robotics. He says top surgeons who already achieve excellent outcomes are frustrated that health systems won't pay them for performing better operations, deciding instead to invest in robotics. "Let's pay the great surgeons more money for doing a better job," says Dr. Kusuma.

He'd be happy to pay out of pocket to have a good surgeon use a robot to achieve an optimal outcome. "But to ask a third-party payer or Medicare to pay for me to have a robotic operation is ludicrous when we have lots of public health problems that need resources dedicated to them," he says.

IN-HOUSE HELP Surgical techs trained to manage needed equipment and supplies play the role of vendor rep.

Replacing reps
Gary Botimer, MD, fully admits vendors' reps bring great value to joint replacement service lines by making sure needed equipment is present, the supply inventory is complete and the surgical team knows how to use proprietary sets of instruments during procedures.

"But once you become an experienced surgeon, you don't need a rep to tell you how to perform the procedure," says the chair of orthopedic surgery at Loma Linda (Calif.) University Medical Center, which recently trained some of its ortho techs to replace vendors during knee replacement procedures. "In fact, you probably shouldn't be doing it if you need a rep in the OR. Vendors are mostly involved in making sure staff are capable, and that's all very trainable."

Instrument and implant manufacturers have to supply instruments, stock an inventory of supplies and pay reps to work cases and organize materials at facilities. Those are all incurred expenses, points out Dr. Botimer, who approached the manufacturers Loma Linda works with about selling their implants directly to the hospital at a fair price, eliminating the need for vendor reps in the facility.

"We did everything we could to take those expenses away from the manufacturer," he says. "We tried to make it a win-win. Except for the reps — it wasn't a win for them."

Administrators at Loma Linda picked top-performing orthopedic techs — who were already familiar with the instrumentation and knew how to perform knee replacements as well as, if not better than, the reps — and contracted with a consulting firm to provide the same 6-month training vendors receive when major instrument manufacturers hire them. The former techs are now known as OR device technicians.

By eliminating reps, Loma Linda now buys implants for $1,500 to $1,900, instead of $4,000 to $7,000 retail. "That's a substantial mark-up we've eliminated," says Dr. Botimer. "But manufacturers are still making good money on what we're paying."

Dr. Botimer also points out that reps tend to upsell surgeons and convince them to use costly equipment they may not need. They also play games with expenses, such as charging extra for disposables that were negotiated into the original per-case cost.

Now that hospital employees are playing the part of reps, those concerns are eliminated and knee replacements are much more profitable, which is especially important in today's healthcare environment. "It's very hard to break even on procedures, particularly when dealing with government payers," he explains.

Health care that's not affordable to patients isn't health care, according to Dr. Botimer. "We feel it's a moral obligation to do what we can to reduce the cost of care without compromising quality," he adds. "Doing away with reps eliminates an unnecessary expense and helps us meet those goals."

Cutting out the middleman when dealing with device and instrument manufacturers involves working through a series of layered and complex issues. Some companies have long-term contracts with distributors and reps, and can't afford to sell directly to facilities, according to Dr. Botimer. In addition, he adds, a lot of marketing is done through relationships between reps and surgeons, and those relationships end up being very expensive for hospitals and, ultimately, patients. He also points out that numerous physicians in teaching facilities and those who frequently publish research receive royalties from companies. It's those vested interests that make it difficult to remove vendors from the equation.

Dr. Botimer suggests you partner with a physician champion with no conflicts of interest to make change happen. "It's initially more work for surgeons and, since the money isn't coming out of their pockets, they don't see a reason to switch," he says. "But when you step back and look at what health care costs, and what we need to do to preserve quality for our patients, it's definitely the ethical thing to do."

BACKBONE OF SUCCESS Spinal anesthesia is one of the keys to lowering rates of post-op mortality and morbidity.

'A spinal every time'
Patients who present for knee replacement are usually older individuals, and an increasing number of them have significant comorbidities. It's a high-risk population and the surgery results in significant pain, so anesthesia providers are faced with significant challenges when caring for these patients.

"PONV and pain need to be controlled," says Colin McCartney, MBChB, PhD, FRCA, FFARCSI, FRCPC, medical director of anesthesiology at The Ottawa Hospital in Ottawa, Canada. "There's some evidence that patients with more significant acute pain after surgery go on to have higher rates of chronic pain."

Dr. McCartney says recently published evidence suggests knee replacement under spinal anesthesia results in lower incidences of mortality, infection, admission to ICU and respiratory complications.

"There's no question regional anesthesia provides better pain control after knee replacement, but unfortunately there hasn't been sufficient argument for facilities to change their practice," he says. "You see that in the rates of general versus regional — approximately 75% of patients still get a general anesthetic for a knee replacement."

There are a multitude of reasons for regional's lack of widespread use during knee replacements, including institutional barriers: The blocks take longer than general anesthesia to take effect, patients expect to receive inhalational and are uncomfortable with being sedated or even awake in the OR, and some surgeons don't want patients awake during the procedure.

There's also a perception that turnover time is faster with general anesthesia, because the induction time is faster, according to Dr. McCartney. "But even though the induction time is slightly slower with spinal anesthesia, the time to getting the patient out of the OR is significantly faster," he explains. "Because the delay happens at the beginning of the procedure during spinal cases, it's perceived to be longer than it really is."

Those challenges will be overcome as more patients seek out facilities performing outpatient total joint procedures, and more facilities adapt to the trend. Surgical administrators will also gain more confidence in implementing regional programs and as the evidence starts to build about the mortality and morbidity benefits of the technique.

Spinal blocks have to be tailored to the surgeon, says Dr. McCartney, who explains lower doses of a spinal anesthetic can be used to encourage early recovery if surgeons can perform procedures in less than an hour. "But if you give a full spinal during quicker cases, the patient may not be able to stand and move around until 5 hours after surgery," he adds.

Some surgeons believe that early ambulation predicts early discharge, but Dr. McCartney says there's actually no evidence in the literature that proves that's true. Pain control is a better predictor, and that's where regional has the advantage, he adds.

"Unfortunately, pain control benefit isn't a big enough argument for most clinicians," says Dr. McCartney, who suggests you consider lower rates of major morbidity and mortality — which ultimately reduce overall healthcare costs — and the potential for greater efficiency. If you can discharge patients earlier or use a model where the spinal block is done outside the OR, you could potentially add an extra case per day.

Regional is also a safer alternative for older, sicker patients who are most likely to seek out facilities that perform same-day knee replacements. In the end, regional results in a better experience. "There's no question that if it was my knee replacement, I'd have a spinal every time," says Dr. McCartney.