Doug ouglas las A. D Denn nnis is, M , M.D. Adjun junct ct - - PowerPoint PPT Presentation

SA SAME D DAY T TKA: A: A ARE RE Y YOU OU CRAZ RAZY? MY PATIENTS A TIENTS ARE W E WELL C CARED F ED FOR

Doug

• uglas

las A. D Denn nnis is, M , M.D.

Adjun junct ct Prof

• fes

essor

• r, Dept.
• t. of Bio

iomed edical al Engine neer ering ng Univ iversity ty of Tenne nnessee Assista tant nt Clin linical al Prof

• fes

essor

• r, Dept.
• t. of Orthop

thopedic c Surgery Univ iversity ty of Color lorado

• Heal

alth th Scien ence ces Cente nter Clini linical cal Dir irec ecto tor Roc

• cky Mtn. Muscul

culos

• skel

elet etal al Resear arch h Laborator

• ry

Denver er, Color

• rad

ado

DISCLOSU DISCLOSURE RE

Consu

• nsult

ltant nt : Dep epuy uy Royalties: s:

• Depuy

puy / Innome Innomed / / Wol Wolte ters K s Kluw uwer

Lab Labor

• ratory Rese

esearch Sup uppo port

• Depuy

puy

• Por
• rte

ter A Adve dventi ntist Hospi st Hospita tal

Ow Owners rship In Inte tere rest: Jo Joint t Vue ue

ADOLPH ADOLPH

Yo You’ve Be ’ve Been en Wor Working ing Much Much Too H

• o Har

ard Yo You’r ’re Asl e Asleep eep At At Th The W Wheel eel On On This his One One !!

THIS THIS I I KNOW !! KNOW !!

Many

ny Sm Small all Stud Studie ies D Demon

• nstrat

ate Outp Outpat atien ient T t TKA C A Can B Be D Done Sa

• ne Safely

ly In A n A Se Sele lect cted Gr Group

• up Of

Of Pa Patie ient nts

I Still H

Still Have A A Lot Lot Of Of Que Questio ions ns

JUS

JUST B BECAUS USE IT CA IT CAN B BE DO DONE NE, IS IS IT THE IT THE B BEST TR TREATMENT METHOD F HOD FOR O OUR P PATIENTS ? TIENTS ??

OUTPATI PATIENT T ENT TKA

If 250

50 Outp Outpat atie ient T t TKA Pa A Patie ient nts A Are e Perfo rforme rmed S d Safe fely & y & One Pa One Patie tient D t Dies ies Or Or Has A A Majo jor C Com

• mplic

lication ion & If & If The he Pa Patie ient nt W Were H Hosp

• spit

ital aliz ized ed & & Em Emer ergency cy T Trea eatm tment nt W Was Admin inis ister ered ed M Mor

• re Pr

e Prom

• mptly

ly, Le Less ssening ing T The M he Magnit itud ude Of Of The he Com

• mplic

lication ion, IS IT

IS IT WORTH RTH IT ?? IT ??

OUTPATI PATIENT T ENT TKA

Many ASCs Are Not On A

Hospital Campus

Is There An Intensivist On Site ? How Long Will It Take ??

• Ambulance To Arrive
• Patient Transport To An Acute

Care Hospital

OUTPATI PATIENT T ENT TKA

Numer

umerou

• us R

Repor eports ts S Show

• w

Similar C lar Comp mplicat icatio ion & Readm admis ission ion R Rates tes Between etween Outpatien tpatient & Inpat npatien ient C t Coho

• hort

rts

Cohorts Are Rarely Matched

• Outpatient Subjects Typically

Younger, Healthier, & More Psychologically Prepared

OUTPATI PATIENT T ENT TKA

IF S

F STUDI DIES WE WERE DON DONE OF OF MA MATCH CHED COH COHOR ORTS ( (AGE GE, MOR MORBIDI DITIES, E ETC. C.) DON DONE INPATIE INPATIENT VS NT VS OUTPATI UTPATIENT, ENT, WOU WOULD COMP LD COMPLI LICA CATIONS & & READM DMISSION ONS R RATES S STILL LL BE T THE SAME ME??

OUTPATI PATIENT T ENT TKA

A Lot

Lot Of Of Out Outpat atie ient nt Knee Knee Arth Arthro roplasty D asty Data ta In Invo volve ves UK s UKA

Will

Will Similar imilar R Res esult ults Be e Ob Obtaine ained Wit With h Out Outpat atie ient nt TKA KA

• Especi

pecially ally I In Medicar care e Aged P d Patien tients ts ? ??

OUTPATI PATIENT T ENT TKA

Whe

When Com Comparing Variabl iables O es Of Similar ilar Incidence, L cidence, Large rge C Cohor

• rt

t Size Size Is Req Is Required T To Detect S ct Small D ll Differences erences

OUTPATI PATIENT T ENT TKA

Are The Idea Are The Ideal Cand Candidates For For Outpatient patient S Surger gery C Clear early ly Identif ntified I ied In Studies dies I Involv

• lving

ing Thou Thousand nds O Of f Pat atient nts ? ??

TKA MORT TKA MORTALITY

May

Mayo Regi Registr try Anal Analysis

• 7

7 Day Day: 0.1% 0.1%

• 30

30 Day Day: 0.2% 0.2%

• 90

90 Day Day: 0.4% 0.4%

Singh ngh & & Le Lewallen, J J Arthr thropl

• plast

sty 2 y 2012

TKA MORT TKA MORTALITY

Power A

wer Analy nalysis is

• Stat C

t Chan ange ge:

– 0.2

.2% To 0 To 0.4 .4%

• 9,425 S

425 Subject jects R Requ quired ired

Studies

udies N Not

• t Avail

ailab able le To D Detect tect Subtle D btle Differen erences ces I In M n Mort rtality ality

OUTPATI PATIENT T ENT TKA

Some Out

• me Outpat

atie ient nt T TKA KA Prot

• tocols
• cols “S

“Send nd T The he Hos

• spit

ital al Home Wit

• me With T

h The he Pat atien ient”

• Visiting RN, HHA, PT

Are They Really Saving $$$ Or

Just Cost Shifting ??

Early D

Disch charg arge N e Not

• t Assoc
• ciated

iated Wit With ↑ Readmis eadmissio ion B But ut Exc Excess ssiv ive Post Postoperative ve ER ER Visits its E Encou countered ered

Cos

Cost Sa Savin vings Vs Vs Shif Shifting ? ??

OUTPATI PATIENT T ENT TKA

Many

Many Out Outpat atie ient nt S Sur urgic ical l Cent Center ers Are P Phy hysicia ician Ow Owne ned

• Surgeons Potentially

Economically Incentivized To Take Patients To Outpatient Surgical Centers

OUTPATI PATIENT T ENT TKA

Will

Will Some S

• me Sur

urgeon

• n Ow

Owne ner Mak Make A A Poor

• or Decis

Decisio ion n Reg egarding ing P Pat atien ient Sele election ion Due Due To

• Sec

econd

• ndary E

Economic conomic Be Benef efit t An And d Adver Adverse Pa se Pati tient t Event ents Occ Occur ur ? ??

OUTPATI PATIENT T ENT TKA

Anes

nesthe hesio iolog logis ist Fear Fears

• Fa

Falls lls: Li Ling nger ering ng A Anes nesthes esia Ef a Effec ects ts

• Postop

Postop B Blee leeding ng (A (Ant ntic icoag agula lant nts)

• Urin

inar ary R Ret eten ention ion → Readmi dmissi ssion

• Epidur

ural H al Hematom

• ma
• Cardi

rdiac A Arrh rrhyt ythmi mia

• Respi

spira ratory D ry Depre pressi ssion

• Pa

Pain in C Contr

• ntrol A

l After er B Blo lock ck C Cessation ion

OUTPA PATI TIENT T ENT TKA: OTHER ER R RIS ISKS

Posto

top R p Respirato piratory Depr pres ession ion

• Obstr

Obstruc ucti tive ve S Sleep A p Apne pnea

– Inc

Incide denc nce Repor ported To B To Be As s Hi High gh As s 23.4% In % In ♀ / 49% In % In ♂

–Ma

Many OS ny OSA Undi Undiagnose gnosed ! !!

–Risk

sk Of Of Respi spirator tory C y Compl

• mplicati

tions

• ns In

In OS OSA Subj ubjects C s Consumi

• nsuming

ng Opi Opiods

• ds For

For Postop P

• stop Pain

n Contr

• ntrol
• l Is S

Is Substa ubstanti tial

–Risk

sks: s: Hypoxi Hypoxia / P / Pne neumoni umonia / / Death

OUTPA PATI TIENT T ENT TKA: OTHER ER R RIS ISKS Pos

• stop
• p Urinar

inary R Ret etent ntion ion

• If U

Undiagn ndiagnosed ed & & Not T

• t Treat

eated ed In In A Timely ely F Fashio ion, n, U Urinar rinary Reten etentio tion C Can n Result ult I In Perman manen ent B Bladd adder D er Damag age, e, Hydro droneph ephro rosis is, , Chro hronic U nic UTI’ I’s, , Etc. c.

SUM SUMMARY ARY

Can Be

Be Done Sa Safe fely In Se Selected Pa Pati tients

Larger Stu

Studi dies R Requ quired To To Defi fine Pr Prope per Patient ient S Select lection ion & Safet ety

FEARS:

EARS:

• Major C

r Comp mplicati cations @ ASCs Locat ated ed D Distan tant From

• m A

A Major

• r H

Hos

• spi

pital

• Surge

geon O Owne nershi hip p → Po Poor Pa r Patie tient Se Select lectio ion

• Increa

reased Resourc rces es R Required red Not A t Availab able e To A All Su l Surg rgeo eons

Not

• t Yet R

t Read eady For For W Wides espread ad U Use ! se !!

THAN THANK K YOU YOU