February 22, 2023

Orthopedics

By: Outpatient Surgery Editors

Published: 2/21/2023

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THIS WEEK'S ARTICLES

"Hyperspecialty" ASCs Found Safe for Total Joints

Are Busier Orthopods More Effective Orthopods?

Marketing and Media Visibility Can Support Your ASC Launch - Sponsored Content

Anesthesia Key to Total Knee Outcomes at ASCs

Technology Advances Can Prevent Lingering Pain in Total Joints Patients

 

"Hyperspecialty" ASCs Found Safe for Total Joints

Comparison with inpatient outcomes reveals no significant differences.

ValueHealthValueHealth
SUITE RECOVERY Patients at ValueHealth Muve’s hyperspecialty orthopedic ASCs can recover for their first couple postoperative days in Stay Suites, where they receive 24/7 monitoring, physical therapy and proper nutrition.

A study by researchers at Rothman Orthopaedic Institute at Thomas Jefferson University in Philadelphia examines an emerging development in the field of outpatient total joint arthroplasty (TJA): "hyperspecialty" ASCs (HASCs) that focus exclusively on total hip arthroplasty (THA) and total knee arthroplasty (TKA). HASCs allow patients to spend additional nights in an extended care suite before discharge.

The study compared 90-day complications and readmissions of TJA patients at an HASC and inpatient TJA at a tertiary hospital. It retrospectively reviewed 1,365 primary unilateral TJAs (658 THA, 707 TKA) performed at four HASCs from 2017 to 2021. Following their procedures, patients were discharged to extended care suites staffed full-time by nurses and physical therapists. These patients were compared 1:1 with 1,365 inpatient TJAs (628 THA, 737 TKA) based on demographics, joint and American Society of Anesthesiologists (ASA) score.

The researchers found no significant differences in ASA≥3 patients or operative times. When comparing 90-day outcomes, no significant differences were found in pulmonary embolism, mechanical complications, periprosthetic joint infections or readmissions. A subgroup analysis of ASA≥3 patients yielded similar findings. There was no difference in age, sex, BMI, ASA or diabetic status between the two groups.

"Patients undergoing outpatient TJA at a novel HASC had similar complication and readmission rates as those undergoing TJA at a tertiary hospital," according to the study. "Based on these data, such facilities seem appropriate for the care of outpatient TJA patients with ASA<4."

The study differentiates HASCs from traditional single-specialty orthopedics ASCs, where post-discharge care occurs at home. In the HASC model, patients are instead discharged to a suite in an adjacent extended care facility, where they stay for two nights under the care of nurse practitioners and physical therapists. "Other elements of this model include an expanded patient engagement program (starting when the patient schedules the surgery until one year postoperatively), standardized business operations and facility designs to improve efficiencies, and evidence-based protocol-driven care pathways to optimize clinical outcomes," the study notes.

The hope is that HASCs will lead to favorable outcomes at lower, more predictable costs in an environment that enhances the patient experience. The study claims to be the first to investigate the safety of outpatient TJA performed at HASCs. "As the trend toward outpatient arthroplasty continues, it is imperative that the orthopedic community continues to evaluate the safety and efficacy of HASCs to determine if this new model of care delivery should be further expanded," say the authors.

Read the full study in Arthroplasty Today, which contains further details about what HASCs are, and how they are structured to provide optimum value-focused TJA care.

Are Busier Orthopods More Effective Orthopods?

New research suggests that the more total knee and hip surgeries they perform, the cheaper and better the surgeries become.

LombardiPUMP UP THE VOLUME A new study finds that surgeons who perform higher volumes of hip and knee replacements generate better outcomes, even when controlling for patient case mix and provider characteristics.

A recent study from Clarify Health, an enterprise analytics and value-based payments platform company that provides actionable patient journey insights to healthcare providers, examines the relationship between the number of orthopedic surgeries a doctor has performed and patient outcomes.

Although surgical volume is widely recognized as a key determinant of healthcare quality, Clarify claims too little publicly available information is available about provider surgical volumes for patients, families and payers. "Healthcare is highly personal, and at the most fundamental level, patients deserve to have agency over the decisions and actions affecting their health," says Clarify Health CEO and founder Jean Drouin, MD. "This research underscores healthcare leaders’ responsibility to make comprehensive surgical volume data widely available to patients, their families and other industry stakeholders to lower costs and improve health outcomes."

"Hip and knee replacements are the most common elective orthopedic surgeries where it is possible for patients to choose their provider," says Clarify Health Institute Chief Analytics and Privacy Officer Niall Brennan. "Thousands of adverse clinical events could be avoided each year by making surgical volume information easily accessible and steering patients to high-volume providers."

"There is a clear linear relationship: The more operations a surgeon performs, the better the patient does," said Ezekiel Emanuel, MD, vice provost for global initiatives at University of Pennsylvania in Philadelphia and a strategic advisor to Clarify Health. "If we shift more patients to get their hip and knee replacements by high-volume surgeons, it will be a huge win-win. Patients will win with fewer complications, fewer revisions and fewer hospital readmissions. And the system will win by having lower costs. Now the challenge is to shift patients to see more experienced surgeons."

The observational study examined over 178,000 orthopedic procedures from more than 23,500 providers, a sample it says accounts for approximately 14% of all hip and knee replacements completed annually in the U.S. Findings in the full report include:

  • Approximately 50% of hip and knee replacement episodes were performed by providers who had performed less than 50 surgeries from 2017 to 2020, while 17% of hip replacements and 13% of knee replacements in 2021 were performed by surgeons with less than 10 prior surgeries.
  • Higher surgical volume resulted in better outcomes across multiple dimensions and care settings, even when controlling for patient case mix and provider characteristics. Post-acute inpatient readmission at both seven and 60 days was between 37% to 51% less for high-volume surgeons compared to low-volume surgeons. Combined rates of post-surgical emergency department visits, inpatient readmissions, and revisions surgeries were approximately 14% lower for hip replacements and 19% lower for knee replacements.
  • Total hip and knee replacement episode costs are approximately $2,800 and $1,500 lower, respectively, when performed by a high-volume surgeon.
  • Combined rates of negative outcomes for patients treated in outpatient and ASC settings are 13% to 24% and 27% to 45% lower on average, respectively, compared to hip and knee replacements performed in inpatient settings.

Embedded in the research is a clear indication that hip and knee replacements performed by high-volume surgeons at ASCs are the safest, least expensive option for patients and payers. The take-home point for ASCs: When it comes to total knees and hips, don’t shy away from turning up the volume when you have capable, experienced, high-volume orthopods in the building.

 

Marketing and Media Visibility Can Support Your ASC Launch
Sponsored Content

Discover practical strategies to educate and influence your community and stakeholders about the services and benefits of your new or renovated facility.

When you’ve decided to move forward with building, renovating or expanding your ambulatory business, it can be challenging. Competition can be intense, resources are limited and getting the word out about your new service is critical for success. Learning about the many communications options and marketing strategies available to you is an important step in the process of creating something new in your community.

Stryker provides ongoing support for success. Part of that ongoing support is a guide, with recommended steps to create and deploy your own marketing strategy to coincide with the opening of your new ambulatory center. It’s important to intentionally drive visibility within the local community so patients and physicians can find you. From establishing a digital presence to hosting an opening event, this guide is meant to empower you with the tools to market and grow your practice.

Among the suggested tactics to achieve awareness is the utilization of the online tools available. A well-done website, for example, is beneficial to communicate your services to patients and the physicians who practice at your center. Websites should be easy to navigate, offer online scheduling and introduce your providers and areas of specialization.

Another effective, low- to no-cost way to promote your ASC is via social media. Unless you choose to advertise, all you have to invest is time and effort to monitor channels and maintain engagement. Taking an active role in your local community may also spread the word about your ASC and build connections.

Creating a Media Outreach Plan

The guide also includes communications tactics and templates, along with useful check lists, to help coordinate your marketing efforts over the course of your renovation or new build. By having a media outreach plan for each stage of the journey, your project is getting attention even before it is complete.

Positive local coverage throughout the process of opening your ASC – from the project’s announcement to the construction process, project milestones, and pre-opening and grand opening events – may help educate your local community and alert interested stakeholders. Live events, such as advance tours or a media briefing, will help showcase the benefits of this new ambulatory center in the region. A variety of tips, activities and templates in the guide help you and your team prepare for reaching out to the media.

The work doesn’t stop after the facility is launched! It is important to keep the information flowing to your patients and your community. Content creation on an ongoing basis may help to engage social audiences. However, it can also be difficult to produce unique content frequently and consistently. Focus on categories related to your practice and include health and wellness tips, information about your individual providers, and highlights of your surgical specialties or community activities.

A strong online presence in your community can help to ensure awareness for the launch of your ASC.

Note: Stryker recognizes that marketing your ASC is an ongoing activity and offers this guide to get you started: visit here. To learn more about Stryker’s ASC business, visit Ambulatory Surgery Center (ASC) | Stryker

 

Anesthesia Key to Total Knee Outcomes at ASCs

Go behind the scenes with one ASC’s successful protocol.

Knoxville (Tenn.) Orthopaedic Surgery Center (KOSC) has run an outpatient total knee replacement service line for five years, and its standardized anesthesia and post-op pain control protocols are a huge component of its success. Its well-considered combination of analgesics and anesthetics can get outpatient knee patients on their way home about four hours after they arrive.

University Anesthesiologists’ Cannon E. Turner, MD, chief anesthesiologist at Knoxville Orthopaedic Clinic, describes the protocol:

Pre-op medications. Patients receive oral acetaminophen, a pain reliever and fever reducer; celecoxib, a nonsteroidal anti-inflammatory drug (NSAID); and a small dose of oxycodone. Younger patients also receive oral gabapentin because of its opioid-sparing effects, but it is administered more selectively in older and at-risk patient populations. Male patients get an oral dose of tamsulosin to help them urinate after the surgery, a criteria for discharge. "We’re trying to minimize narcotics, which is why we’re starting off with that small oral dose of oxycodone in conjunction with nonopioid adjuncts in the hope that it will be the only narcotic they receive," says Dr. Turner. Patients are sedated just enough to be comfortable intra- and postoperatively, but not so groggy that they’ll need several hours in the PACU.

Pre-op spinal anesthetic. Patients receive a low-dose injection of ropivacaine. "Our goal is to give the lowest effective dose, so we have surgical anesthesia in the OR while also promoting a timely recovery of their motor function," says Dr. Turner. They also receive a low dose of midazolam instead of narcotics like fentanyl immediately before the spinal injection is placed, which helps them wake up faster postoperatively.

Patients sit up for the spinal injection and then are laid down for adductor canal and iPACK blocks placed via ultrasound guidance. They receive 20mls of 0.5% ropivacaine for the adductor block and 10mls of ropivacaine for the iPACK block. These low-volume, single-shot blocks have a higher concentration of anesthetic, providing patients appropriate analgesia with no muscle paralysis or motor block. "We keep the volume low because we don’t want patients to be unable to move their calf after the spinal wears off," says Dr. Turner. "That would delay their discharge because they’d be a fall risk at home." Combining the two low-volume blocks helps to avert potential side effects from each of them. To prevent PONV, patients receive IV ondansetron and decadron, sometimes with a scopolamine patch.

Intraoperative measures. After patients arrive in the OR and are draped and prepped, IV propofol is administered as the sole anesthetic via MAC sedation using an infusion pump. The pump allows patients to breathe spontaneously and reduces risks of excessive sedation and nausea. "Their return to consciousness and their time in PACU is much shorter after the IV medications and propofol than it would be if we used inhaled general anesthetic gases," says Dr. Turner.

When the procedure is complete, surgeons inject a combination of a local anesthetic and an analgesic into the joint. Depending on the surgeon, the local anesthetic is ropivacaine or bupivacaine, while the analgesic is ketorolac, morphine or ketamine. "The thought is that injecting right at the site, where it needs to work, will increase the analgesic effect of everything else we’ve done," says Dr. Turner.

The PACU. When most of KOSC’s patients wake up, the effects of the spinal anesthetic are regressing while the nerve blocks and joint injection are working. Patients are comfortable, able to urinate, and can eat and drink. They must walk up a test physical therapy staircase and, if they can ascend it, they’re nearly ready to go home.

"In terms of medication, hopefully that’s it," says Dr. Turner. "Sometimes a patient will need a dose of something before they leave — acetaminophen, ketorolac or, in rare instances, a narcotic — but more often than not, all the work was done beforehand, so everything is optimized and they’re soon in their car going home."

 

Technology Advances Can Prevent Lingering Pain in Total Joints Patients

No robot? No problem!

A small percentage of joint replacement patients experience lingering postoperative pain, even though their implants seem well-positioned. New advances in joint replacement technology aim to alleviate these unseen issues. "The hope is that this technology will eliminate those outliers to make a good procedure an even better one," says Kyle J. Hubler, DO, orthopedic surgeon at UPMC in north central Pennsylvania.

Robotic assistance generally dominates these discussions, but other areas of innovation are empowering surgeons to better prevent postoperative pain among joint replacement patients. These include:

Handheld navigation. This technology helps surgeons improve the accuracy of implant alignment without a full robotic system. These systems, the size of a smartphone, often use micro-electromechanical sensors such as gyroscopes and accelerometers to register patient anatomy and provide live navigation of instruments to help surgeons with precise implant placement.

Smart implants. Aiming to provide an entirely personalized approach to each total knee patient, surgeons can choose a smart implant that best matches a patient’s specific anatomy. A smart sensor attached to the bottom of the implant captures data like range of motion, stride length, walking speed and step count, and sends it to an app that the surgeon can access to monitor the patient’s recovery.

Anterior approach for hip replacements. This approach is performed from the front of the hip, which causes less damage to surrounding muscle and tissues than the more common posterior approach. Surgeons who have embraced this technique say it requires fewer, smaller incisions that allow the patient to recover more quickly with fewer movement restrictions postoperatively.

Multimodal pain management. These protocols have had a large and lasting impact on patient outcomes over the past decade. "Nerve blocks, periarticular injections with pain medicine, physical therapy with early mobilization and limited use of narcotics have all been able to help us mobilize and rehab patients faster with less pain and discomfort," says Dr. Hubler.

ASCs and their patients can benefit from these emerging approaches whether they have surgical robots or not.

 

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