Patient Outcomes Following Total Joint Replacement Surgery: A Comparison of Hospitals and Ambulatory Surgery Centers

Abstract

Background: For several years, many orthopedic surgeons have been performing total joint replacements in hospital outpatient departments (HOPDs) and more recently in ambulatory surgery centers (ASCs). In a recent shift, the Centers for Medicare and Medicaid Services began reimbursing for total knee replacement surgery in HOPDs. Some observers have expressed concerns over patient safety for the Medicare population particularly if Centers for Medicare and Medicaid Services extends the policy to include total hip replacement surgery and coverage in ASCs. Methods: This study used a large claims database of non-Medicare patients to examine inpatient and outpatient total knee replacement and total hip replacement surgery performed on a near-elderly population during 2014-2016. We applied propensity score methods to match inpatients with ASC patients and HOPD patients with ASC patients adjusting for risk using the HHS Hierarchical Condition Categories risk adjustment model. We conducted statistical tests comparing clinical outcomes across the 3 settings and examined relative costs. Results: Readmissions, postsurgical complications, and payments were lower for outpatients than for inpatients. Within outpatient settings, readmissions and postsurgical complications were lower in ASCs than in HOPDs but payments for ASC patients were higher than payments for HOPD patients. Conclusion: Our findings support the argument that outpatient total joint replacement is appropriate for select patients treated in both HOPDs and ASCs, although in the commercially insured population, the latter services may come at a cost. Until further study of outpatient total joint replacement in the Medicare population becomes available, how this will extrapolate to the Medicare population is unknown.

Analysis of patient characteristics, health care costs by surgical venue, and opioid utilization for common orthopedic procedures in the United States

“…These results align with a previous study that found lower costs of combined surgical and postsurgical care up to 90 days for ASCs compared with inpatient venues for TKA (13%) and THA (15%). 8 Interestingly, this previous study also found that surgical and postsurgical costs of TKA and THA were higher in ASCs compared with HOPDs (~5% for both procedures). 8 Taken together, the findings from the current retrospective analysis of > 126,000 patients support previous reports among smaller samples indicating that shifting more procedures to HOPDs or ASCs from inpatient settings can reduce medical costs.…”

“…8 Interestingly, this previous study also found that surgical and postsurgical costs of TKA and THA were higher in ASCs compared with HOPDs (~5% for both procedures). 8 Taken together, the findings from the current retrospective analysis of > 126,000 patients support previous reports among smaller samples indicating that shifting more procedures to HOPDs or ASCs from inpatient settings can reduce medical costs. Future research using large claims databases or other sizable real-world sources can confirm whether these trends will continue.…”

“…For example, an analysis of commercial insurance claims for patients undergoing total knee arthroplasty (TKA) or THA in which ASC and inpatient procedures were propensity score matched on a clinical risk profile found that, in addition to lower costs (payments) for the ASC procedures compared with inpatient procedures, postsurgical costs (all postsurgical care payments through 90 days after surgery) at ASCs were 8% and 21% lower than postsurgical cost outcomes at an inpatient setting for TKA and THA procedures, respectively. 8 Although economic benefits favor outpatient surgery centers for orthopedic procedures, these benefits may also be reflective of the condition of patients eligible for outpatient surgery, who are often younger and generally present with minimal notable medical history and who presumably are at low risk of experiencing surgical complications. 9,10 It is unknown whether elements of postsurgical care, such as prescription opioid use for postsurgical pain control, differ between inpatient and outpatient surgical venues.…”

Timeline and Procedures on Restarting Non-Emergent Arthroplasty Care in the US Epicenter of the COVID-19 Pandemic

“…Ambulatory arthroplasty has been a growing trend in the USA for several years. Advocates have emphasized the safety of outpatient procedures and the avoidance of inpatients risks [4]. In the era of COVID-19, same-day or short-stay surgery is especially appealing.…”

Introduction of Day Case Hip and Knee Replacement Programme at an Inpatient Ward is Safe and May Expedite Shortening of Hospital Stays of Traditional Arthroplasties

“…SDD arthroplasty can be performed at dedicated Ambulatory Surgical Centres (ASC), hospital outpatient surgery departments (HOSD) and at hospital inpatient wards. The safety of DCA on selected patient population is well documented in all these settings [14,16,17]. Recent publications comparing the inpatient versus outpatient settings concluded that the latter is more time e cient and patients are more likely to achieve discharge criteria on the day of surgery [14,18].…”