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

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 • 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! ADULT RECONSTRUCTION AND JOINT REPLACEMENT

My Opponent: Dr. Keith Berend • Expert Surgeon • Forward thinker • Implant Designer • Process Improver ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Outpatient Total Joint Replacement: Only one question ! 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 ? 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 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 ! 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 operation ! – Think childbirth – Same process but hosp stay 7 days (1950’s) to drive by birthing (2017) ADULT RECONSTRUCTION AND JOINT REPLACEMENT

ADULT RECONSTRUCTION AND JOINT REPLACEMENT Total Joint Replacement: It’s not without risk !

Total Joint Arthroplasty : Orthopaedic Risks • Total Hip or Total Knee: – Infection – Nerve palsy – Fracture – Vascular compromise 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 ! ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Mortality after TJR • “ Death is the ultimate complication which is to be avoided!” 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 ! 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 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 Belmont et al JBJS Jan complications 2014 – 0.18% mortality 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 # of comorbidities – When ? Memtsoudis et al J Orthop Res 2012 • POD #4 TKR • POD #6 THR 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 ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Fatal or Near-Fatal Complications: When ?? ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Fatal or Near Fatal Complications • Peak incidence at 48 hours • 90% within 96 hours of admission • Predisposing factors: – Increasing age – Increasing BMI – BUT…… • 58% had no identifiable Parvisi et al JBJS 2007 risk factors !!! ADULT RECONSTRUCTION AND JOINT REPLACEMENT

ADULT RECONSTRUCTION AND JOINT REPLACEMENT Will these real risks disappear if we go to the outpatient setting ?

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 ! ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Who really benefits from outpatient total joint replacement ? Patients / Payors / Providers 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 ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Outpatient TJR: “there’s no place like home…….” ADULT RECONSTRUCTION AND JOINT REPLACEMENT

I think its more like a Jedi mind trick! ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Outpatient TJR: The Payors • In the long run, they will probably figure out where the money is going and “squeeze” the system downward ! • Amb Surgery joint replacement is clearly cheaper ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Outpatient TJR: The Payors: A New Reality ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Outpatient TJR: What about the Providers ? • Don’t have to round ! (nice!) • Sources of income: surgical fee “hotelier” fee ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Unfortunately ADULT RECONSTRUCTION AND JOINT REPLACEMENT

How do we currently get paid ? ADULT RECONSTRUCTION AND JOINT REPLACEMENT

What makes up the work RVU? ADULT RECONSTRUCTION AND JOINT REPLACEMENT

TJR Goes to Ambulatory ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Congratulations: You’ve just earned a 17% reduction in your fee ! ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Don’t fret: Lots of opportunities to make up the difference ! ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Outpatient TJR: I should be more like Keith ! ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Outpatient TJR: A confession I’m Slow to Change 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 ! 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 ? ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Outpatient Total Joint Replacement: One last question ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Outpatient total joint replacement ADULT RECONSTRUCTION AND JOINT REPLACEMENT

ADULT RECONSTRUCTION AND JOINT REPLACEMENT Thank You