Total Knee Replacement Outpatient Surgery Abraham Abdo, MD - PDF document

3/2/2018 Total Knee Replacement Outpatient Surgery Abraham Abdo, MD Orthopedic Surgery 2698 N. Galloway Ave Mesquite, TX 75150 Modern Era of Total Knee Arthroplasty began with Gunston in 1971 1

3/2/2018 Many of the problems encountered with early designs have been defined and appropriate solutions have been identified. New designs took into consideration problems with • Patellofemoral pain • Alignment • Tracking • Polyethylene wear • Instrumentation Arthritis affects about 40 million Americans, 1 in 8 people. 700,000 TKA are performed annually. 2

3/2/2018 Painful Arthritic Knee Joint that failed to respond to conservative therapy that includes: • Medications • Physical Therapy • Modification of Activities • Injections • Arthroscopy Surgical Procedure 3

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3/2/2018 Past 20 years duration of hospitalization for TKA in U.S. has decreased from 9 to 4 days. The hospital cost for TKR has increased. Therefore, reduction in length of stay remains an important target for cost containment. 9

3/2/2018 Pain management and anesthesia advancement has played a big role in transitioning total joints to outpatient setting. Projected Outpatient Surgery for Joint Replacement 60 50 • 2016: 15% • 2018: 25% 40 • 2020: 32% 30 • 2022: 37% 20 • 2024: 43% 10 • 2026: 51% 0 2016 2018 2020 2022 2024 2026 Beginning of 2018, CMS removed Total Knee Replacement from the inpatient only list. 10

3/2/2018 • Reimbursement rate of $12,384 for inpatient and $10,122 for outpatient surgery would result in 18% decrease in reimbursement for providers. • A saving of $311 million for Medicare. Pathway to Outpatient TKR • Preoperative Screening ‐ comorbidities • Patient Education & Expectation Alignment • Pain Management & Early Mobilization • Minimization of Blood Loss ASA Class 1‐3 BMI 35 or less Age 70 years old or younger 11

3/2/2018 Inpatient Certification • High Risk for DVT HX A FIB Mechanical Heart Valve HX VTE in past 3 months • One or more of the following comorbidities: DM, BMI>35, Cardiac: CAD, HF, AMI COPD, Sleep Apnea, Dementia, Falls 10.2 % of outpatient TKR procedures were readmitted within 30 days Compared to 6.6% of the inpatient procedure group. • Will our patient want this? • Are the physicians on board? • Are the facilities appropriate? • Limitations of the staff? • How will we select patients? • What will happen before, during, and after? • Are we confident in our value proposition and minimum reimbursement rates? • Marketing? • Evaluate our successes and failures. 12

3/2/2018 In Summary Whether our goal is to reduce length of hospital stay or eliminate it, proper planning must be done to insure patient safety and success. 13