The healthcare delivery system in the United States is considered the most expensive in the world, and the future need for joint replacements is sure to worsen the economic pressures. Same-day surgery for hip and knee replacements has been shown to be safe and effective — when done in the setting of a comprehensive approach to patient engagement, modern pain management, vetted pathway selection methods and cloud-based systems for homecare and patient reported outcomes. Accordingly, there is a growing interest among patients and payers alike in transitioning joint replacement to the more cost-effective, ambulatory settings.
Dr. Vinod Dasa is an associate professor at Louisiana State University in New Orleans who recently joined the growing number of joint replacement specialists utilizing the SwiftPath Program. He was one of the speakers at a SwiftPath Symposium in San Diego where he addressed the topic of joint replacement surgery without implant representatives in the room. His team recently published an IRB-approved series of 292 patients who underwent TKA at a university-based orthopedic practice from 2011-15. The patients were stratified into two groups: outpatient (LOS ≤ 1 day) and inpatient (LOS two to four days).
The outpatient group had higher WOMAC and Oxford scores compared to the inpatient group. They also had fewer complications. The authors concluded that patients staying in the hospital for less time, spending less money and decreasing exposure to nosocomial infections, results in similar if not statistically significant better outcomes measured by WOMAC pain, function, and stiffness and Oxford knee score.
According to Dr. Dasa, their research supports that same day total joint replacements are equally as effective and possibly even more effective than the traditional inpatient model. “The SwiftPath Program is the only solution I’ve seen to effectively scale this across the country. Our research supports what the SwiftPath Program wants to achieve and patients will benefit as a result,” said Dr. Dasa.
The LSU experience has been corroborated by data published from the SwiftPath team and data that is being collected by SwiftPath Surgeons. The SwiftPath team published their experience based on over 500 outpatient joint replacements. According to Dr. Craig McAllister, chief medical officer of SwiftPath, “across the country, we are seeing success in terms of shortened length of stay, decreased use of skilled nursing facilities, fewer readmissions, and greatly reduced costs related to joint replacement surgery. Even more gratifying, the patients are happier with the overall experience of care.”
Dr. McAllister and Dr. Dasa agree that the benefits of ASC joint replacement have to be balanced against a number of challenges, many of which represent opportunities for improvements in the way joint replacements are done.
According to Dr. Dasa, “Especially in the ambulatory setting, instrument and tray management are going to be important. Can we continue to survive with eight to 10 trays for a total joint replacement or can we consolidate instruments and start becoming a little more knowledgeable and efficient in how we manage this? Can we go from this antiquated model of redundant instruments, tote boxes and unnecessary, inefficient utilization of resources into something that's much more efficient for this day and age?” In 2015, Dr. Dasa started doing outpatient total joint replacements without commercial vendors in his room. “Then we started developing the technology to change the paradigm. In 2016, we created our automated implant delivery model, which we feel is probably the lowest cost, most efficient model delivering care at under $6,000.”
Dr. McAllister performs over 74 percent of his hip and knee replacements on an outpatient basis in a community hospital as well at the Proliance Eastside Surgery Center in Kirkland, Wash. He points out that “ASC joint replacements are distinctly different from hospital-based joint replacements. ASCs do not have central supply, loading docks and large storage areas. Also, in ASCs, the surgeons are much more empowered, have direct and consistent communication with their staff, and have more hands-on involvement than we have at hospitals. ASCs must simply be smarter and more efficient in their management of instruments and implants. At the hospital, I would never dream of trying to manage joint replacements without the full support of implant representatives. I am much more comfortable and accustomed to managing instruments and implants without the assistance from commercial reps in my ASC. I feel that this will change the relationship that I have with my implant reps and will help reduce the costs related to the implants.”