Outpatient Total Hip Replacement: Be Careful What You Ask For ! - - PowerPoint PPT Presentation

▶
outpatient total hip replacement be careful what you ask
SMART_READER_LITE
LIVE PREVIEW

Outpatient Total Hip Replacement: Be Careful What You Ask For ! - - PowerPoint PPT Presentation

Nov 07, 2022 269 likes •685 views

ADULT RECONSTRUCTION AND JOINT REPLACEMENT Outpatient Total Hip Replacement: Be Careful What You Ask For ! Douglas E Padgett, MD C.S. Ranawat Chair Adult Reconstruction and Joint Replacement Hospital For Special Surgery Disclosures

slide-1
SLIDE 1

ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Outpatient Total Hip Replacement: Be Careful What You Ask For !

Douglas E Padgett, MD C.S. Ranawat Chair Adult Reconstruction and Joint Replacement Hospital For Special Surgery

slide-2
SLIDE 2

ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Disclosures

  • Consulting / Royalties: DJO
  • Stock Options: PixarBiio
  • Boards:

– Journal of Arthroplasty – The Hip Society – American Joint Replacement Registry

  • I Do Not Own Nor Do I Have a Financial Stake in

any healthcare facility!

slide-3
SLIDE 3

ADULT RECONSTRUCTION AND JOINT REPLACEMENT

My Opponent: Dr. Keith Berend

  • Expert Surgeon
  • Forward thinker
  • Implant Designer
  • Process Improver
slide-4
SLIDE 4

ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Outpatient Total Joint Replacement: Only one question !

slide-5
SLIDE 5

ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Outpatient TJR: My tactics in 2017

  • Explore these concepts:

– Can we do it ? Keith has shown this ! – Should we do it ? – Who does it benefit ? – Might we regret it ?

slide-6
SLIDE 6

ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Total Joint Replacement:

The “worlds” best medical intervention

  • The highest

improvement in quality of life years

  • Trails only smoking

cessation as a cost effective measure

slide-7
SLIDE 7

ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Total Joint Replacement

  • Despite these

successes, we continue to try and “f*#k it up!” via design

– MOM thr – Modular thr – The “Duece”

  • My fear is that this

trend may now be in the realm of delivery !

slide-8
SLIDE 8

ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Concerns: Perception vs Reality

  • Total Joint Replacement is

not really a big deal ! – MIS surgery – Outpatient surgery – “rapid recovery”

  • Reality: it is still the same
  • peration !

– Think childbirth – Same process but hosp stay 7 days (1950’s) to drive by birthing (2017)

slide-9
SLIDE 9

ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Total Joint Replacement:

It’s not without risk !

slide-10
SLIDE 10

ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Total Joint Arthroplasty : Orthopaedic Risks

  • Total Hip or Total

Knee:

– Infection – Nerve palsy – Fracture – Vascular compromise

slide-11
SLIDE 11

ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Total Joint Arthoplasty: Medical Morbidity

  • Cardiovascular
  • Renal
  • Endocrine

– Let’s face it, any organ system can be at risk !

  • Death !
slide-12
SLIDE 12

ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Mortality after TJR

  • “ Death is the

ultimate complication which is to be avoided!”

slide-13
SLIDE 13

ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Total Joint Arthoplasty: Why a “big” deal ?

  • It’s all about the

bone!

  • Metabolic affects of

invasion of the long bones !

– Hematologic – ? Procoagulants

  • This makes what we

do: NOT BENIGN !

slide-14
SLIDE 14

ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Total Joint Arthroplasty: Risks The HSS Experience:

  • Data Source:

– ARHQ funded study – 6 month complications collected – THR Data:

  • 6311 patients
  • 4.2% complication rate

– DVT / PE – Infection – Bleeding – Pneumonia – CVA / MI Thanks to Lily Lee & Amethia Holmes, ARJR HSS

slide-15
SLIDE 15

ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Total Joint Arthroplasty Risks: What are the numbers ?

  • 30 Day TKR
  • Data Source:

– 15,000 knees – National Surgical Quality Improvement Program (NSQIP)

  • Results:

– 5.6% complication rate

  • Age, BMI, and operative

length predictive of complications

– 0.18% mortality

Belmont et al JBJS Jan 2014

slide-16
SLIDE 16

ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Total Joint Arthroplasty: Epidemiology of Periop Mortality

  • 1998-2008 NIS data:

– 4.4 million TKR/ 2.1 million THR – Mortality:

  • 0.13% TKR
  • 0.18% THR

– Who ?

  • Older, male, increase #
  • f comorbidities

– When ?

  • POD #4 TKR
  • POD #6 THR

Memtsoudis et al J Orthop Res 2012

slide-17
SLIDE 17

ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Complications of Total Joint Replacement : The When !

  • Rothman Institute

– 900 THR – 670 TKR – 104 “life threatening complications” (6.2%)

  • Cardiac arrthymias
  • PE
  • CHF
  • Renal Failure
  • MI / CVA
slide-18
SLIDE 18

ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Fatal or Near-Fatal Complications: When ??

slide-19
SLIDE 19

ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Fatal or Near Fatal Complications

  • Peak incidence at 48

hours

  • 90% within 96 hours
  • f admission
  • Predisposing factors:

– Increasing age – Increasing BMI – BUT……

  • 58% had no identifiable

risk factors !!!

Parvisi et al JBJS 2007

slide-20
SLIDE 20

ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Will these real risks disappear if we go to the outpatient setting ?

slide-21
SLIDE 21

ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Total Joint Replacement Recovery: What do you get in the hospital ?

  • Nursing care

– Medications – Wound care – Nutritional monitoring

  • Physical Therapy

– Assistance with mobility

  • Oh yes ….. Surgeon

rounding !

slide-22
SLIDE 22

ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Who really benefits from outpatient total joint replacement ? Patients / Payors / Providers

slide-23
SLIDE 23

ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Outpatient Total Joint Replacement: The Patients

  • Still have trouble with

this one !

  • Safety of one’s own

home

  • Comfort of familiar

surroundings

slide-24
SLIDE 24

ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Outpatient TJR: “there’s no place like home…….”

slide-25
SLIDE 25

ADULT RECONSTRUCTION AND JOINT REPLACEMENT

I think its more like a Jedi mind trick!

slide-26
SLIDE 26

ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Outpatient TJR: The Payors

  • In the long run, they

will probably figure

  • ut where the money

is going and “squeeze” the system downward !

  • Amb Surgery joint

replacement is clearly cheaper

slide-27
SLIDE 27

ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Outpatient TJR: The Payors: A New Reality

slide-28
SLIDE 28

ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Outpatient TJR: What about the Providers ?

  • Don’t have to round !

(nice!)

  • Sources of income:

surgical fee “hotelier” fee

slide-29
SLIDE 29

ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Unfortunately

slide-30
SLIDE 30

ADULT RECONSTRUCTION AND JOINT REPLACEMENT

How do we currently get paid ?

slide-31
SLIDE 31

ADULT RECONSTRUCTION AND JOINT REPLACEMENT

What makes up the work RVU?

slide-32
SLIDE 32

ADULT RECONSTRUCTION AND JOINT REPLACEMENT

TJR Goes to Ambulatory

slide-33
SLIDE 33

ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Congratulations: You’ve just earned a 17% reduction in your fee !

slide-34
SLIDE 34

ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Don’t fret: Lots of opportunities to make up the difference !

slide-35
SLIDE 35

ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Outpatient TJR: I should be more like Keith !

slide-36
SLIDE 36

ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Outpatient TJR: A confession I’m Slow to Change

slide-37
SLIDE 37

ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Transition to Outpatient TJR

  • I’m not worried about

the money !

  • The hospitals will

figure out how to survive !

  • The payors will

prosper !

slide-38
SLIDE 38

ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Outpatient TJR: My concern: is the patient !

  • When you have your

“arrest”…..

– Where do you want to be ?

  • Hospital ?
  • Home ?
slide-39
SLIDE 39

ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Outpatient Total Joint Replacement: One last question

slide-40
SLIDE 40

ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Outpatient total joint replacement

slide-41
SLIDE 41

ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Thank You