The preferred method for performing most joint replacement operations is in the outpatient setting.
We have pioneered outpatient joint replacement surgery at Midlands Orthopaedics and Neurosurgery. We began in 2012, as one of the first groups in the country, and have performed thousands of joint replacements of all kinds in the last 8 years. We have now perfected this to the point that most of my joint replacements are done as outpatient procedures. Local patients go home several hours after the operation and follow-up with me in the office 1 week later. Out of area patients go to a hotel instead where I see them the next morning before they begin their drive home. Patients flying home are advised to spend a second night in the hotel before flying. Only patients with more complex operations, certain serious comorbidities or those with uncooperative insurance plans are still done at the hospital.
Most patients who have had one procedure done at the hospital and another as an outpatient much prefer the latter. The outpatient approach is safe, convenient, friendly, less costly, and avoids exposure to hospital infections. One requirement to qualify for outpatient surgery is to bring a capable and responsible caretaker (family or close friend at least 18 years of age) with you.
When I trained in Orthopedics at Johns Hopkins over 30 years ago it was routine to keep patients in hospital for 2 weeks and then send then to a skilled nursing center for another 2 weeks. Now we perform the surgery outpatient, with the patient going home several hours after surgery. Usually patients are off narcotics and can drive in 3-5 days and return to office work in 1-2 weeks. Most of the country is following our lead and the process has accelerated during the COVID pandemic. What has led to this development? There are numerous factors, both traditional, clinical and economic that are responsible.
The three most common reasons that joint replacement patients have traditionally required a hospital stay are: managing blood loss, controlling pain, and monitoring those with major medical comorbidities. In the first 20 years of my private practice I gradually improved the process of joint replacement to the point where we were only routinely keeping patients one night in the hospital. For years none of them required transfusions even after bilateral surgery and pain control was so good that few needed anything but oral medication. Our Group owns a surgical center where we had been performing outpatient orthopedic surgery of all types very safely and cost effectively for years. In 2012 we made an agreement with one of our major insurers to begin moving joint replacement and spine surgery to our center. Over time we have continued to gradually expand the indications for outpatient surgery and have compiled an excellent safety and patient satisfaction record [LINK TO MOSC website]. We now control the entire patient experience and no longer need to depend on an inefficient and overpriced hospital partner to implement changes.
I have not had to transfuse a primary joint replacement patient in over ten years. Improved minimally invasive surgical technique, careful preoperative preparation, tissue sealers, tranexamic acid, and platelet concentrate with thrombin, irrigation with epinephrine solution and selective use of cell savers have all contributed to eliminating the need for transfusion. Only a few years ago the national transfusion rate for joint replacement was in excess of 30%. Mine has been zero for over 10 years.
Pain management has also dramatically improved in the last 2 decades. Multimodal pain management starting preemptively with a combination of maximum dose Tylenol, antiinflamatory meds, ice therapy, platelet concentrate, long-acting local anesthetic injections and oral slow and fast release narcotics has totally changed the surgical experience for patients. Using short acting blocks (spinal, lumbar plexus, or femoral-sciatic) that wear off quickly after the surgery means patients usually do not experience much pain in the process. While the block is wearing off in the recovery room the nurse slowly dials in any required narcotic. With a anesthetic block this transition out of surgery is usually quite smooth and is the last time injectable narcotics are required. Patients are able to walk out of the surgery center and ride home very comfortably after several hours. Narcotics are usually only required for 3-5 days for hips and 2-3 weeks for knees.
Patients with certain comorbidities can sometimes be accommodated with an additional overnight observation period in our center. If the comorbidities are too severe the surgery must still be done in hospital.
Infection is one of the worst complications to arise from a joint replacement. Despite our best efforts, no operation is truly sterile. Some bacteria enter the wound during every surgery. Usually the human immune system can eradicate these and prevent an infection. If an artificial implant is present, it is harder for the immune system to do its job. Then, after the surgery, it is a race for the skin to totally seal and prevent bacteria on the skin from entering and creating an infection. Infection that develops by one of these two methods is called a perioperative infection, because there is no way of knowing exactly how the bugs got in. Hospitals and surgery centers are required to report to the government any joint replacement infections that develop by three months postop. This captures many perioperative infections, but really a year is needed to be sure.
Rarely infection can still spread to the joint at any time in your life from an infection elsewhere in the body through the bloodstream. Infections that occur after 1 year are late infections; they are NOT perioperative. They are not caused by the operation itself and are not under the control of the surgeon. Fortunately, they are rare. I estimate a lifetime risk for late infections is well below 1%.
We focus on the 3-month and 1-year perioperative infection rate because the surgeon has control of this. The 3-month perioperative infection rate at our center is well below 1%. My personal 3-month rate in the last 10 years is zero. You can find online data for any hospital but not by surgeon. From scientific studies we estimate that the national benchmark 1-year infection rate is approximately 2.5% and growing. Hospitals and surgery centers don’t collect 1-year data. My personal rate for the last 10 years has been 0.1%. One factor that allows me to have a 1-year infection rate 25 times lower than the national benchmark is the fact that this surgery is performed mostly at a surgery center (where I have ownership control) and not a hospital where sick patients bring in lots of bacteria.
The cost of doing joint replacement at a surgeon owned outpatient center is lower in our center and across the country. Hospitals all across the country have spent the last two decades consolidating into huge hospital groups that own most doctors’ practices. This process has been accelerated by the Obamacare rules. Hospitals have largely been successful in creating near monopoly positions in most markets and have used this leverage to dramatically raise prices, At the same time government rules (certificate of need, CON) make it nearly impossible for anyone to build a new independent hospital to challenge the hospital monopoly. But the advancements that have allowed us to transition major operations to an outpatient center have allowed independent (not hospital owned) surgeon groups like ours to challenge this hospital stranglehold. As this trend accelerates, we hope that more surgeons are lured out of hospital employment and start their own outpatient programs. Also because of CON rules it is difficult but not impossible to build new outpatient centers. But, as surgeon owned outpatient centers proliferate, the cost of surgery will go down while the quality rises as we have shown in our center. The free market in medicine has been severely distorted by crony capitalism driven by government regulation. All aspects of the medical system need to be reformed to promote transparency and competition. Hospitals and their employed surgeons at major medical centers have fought this development, but the value proposition for the patient and their insurer is too strong… this new model is growing rapidly. We are proud to be one of the first groups in the country to pioneer this approach.
Insurance contracting is complex and byzantine. But I will give an example using approximate numbers. Total cost for joint replacement at our center is $28,000 with one major insurer. This insurer posts on their website that the cost at the three major hospitals in the Columbia metro area are $35,000, $45,000, and $60,000. There are other hospitals in the country where the cost can be as high as $100,000. Hopefully the federal government will enforce the recent executive order for price transparency which will allow all patients to make cost comparisons in advance.