Popularity of outpatient orthopaedic surgery increases throughout Europe

It is known by several names: same-day surgery, day-case surgery, ambulatory surgery and outpatient surgery. Whatever the name, outpatient orthopaedic surgery is now considered by many to be safe and feasible across an ever-widening array of joints — hips, knees, hands, ankles and spine. Proponents of these procedures say they have the potential to increase patient comfort and satisfaction while improving hospital efficiency and reducing health care costs.

However, there are concerns among some physicians about this type of surgery.

“There is a big pressure towards ambulatory surgery because it is cheaper from a health care perspective,” said Peter Verdonk, MD, PhD, of Belgium. “The downside of it is we are pushing patients outside of the hospitals into their homes and sometimes there is a safety issue associated with the early move towards the home situation.”

Furthermore, there are barriers to widespread adoption of these procedures across Europe, with lack of reimbursement and different cultural views in some countries being among the largest. Many experts believe some orthopaedic procedures are just too complex to do as outpatient surgery.

In this Cover Story, Orthopaedics Today Europe talks to the experts in various orthopaedic subspecialty areas about the rationale, patient selection, surgical planning and potential complications of same-day orthopaedic surgery.

Differences between EU countries

Many orthopaedic surgeries can be done in the ambulatory setting, but this varies by country.

“There are large differences between countries, between cultures, even within the European space,” Verdonk, who specializes in knee surgery, said. “So, there is nothing generalizable. But meniscectomies and cartilage procedures are the bulk of what we can do safely during ambulatory surgeries.”

Same-day ACL reconstructions are common in France, according to Bertrand Sonnery-Cottet, MD, of Lyon, France, who annually performs 700 outpatient ACL reconstructions.

In addition, reports show it is possible to perform certain spine procedures, such as kyphoplasty and vertebroplasty, as same-day procedures. Some surgeons also perform outpatient total hip and knee replacements.

Patient selection

Proper patient selection is usually critical to the success of these cases.

“They need to be motivated to go home on the same day, for one, which to our surprise is the majority of the patients,” said Stephan Vehmeijer, MD, PhD, of Delft, The Netherlands.

The optimal patient for a same-day case is someone who is healthy and had no known significant comorbidities.

“We do not want any patients with prior myocardial infarctions or brain infarctions to be in the same-day procedure because of the increased risk of cardiovascular complications in the first 24 hours,” said Vehmeijer, whose clinic has performed about 100 outpatient total hip replacement (THR) cases since April 2014.

Patients with insulin-dependent diabetes are also excluded from same-day procedures, he said.

“It is a very short list of patients that are not able to join the program,” Vehmeijer told Orthopaedics Today Europe.

Verdonk uses the American Society of Anesthesiologists (ASA) Physical Status Classification System, which evaluates the physical fitness of patients prior to surgery, to guide patient selection. “ASA I or II are generally patients you can safely perform surgery in the outside patient clinic,” he said.

Social support is an important component to consider when assessing a patient for possible outpatient surgery because patients typically need support at home before they can be discharged.

“[Patients] should not spend the night [after surgery] alone,” Verdonk said. “The social structure around the patient is important.”

Some surgeons feel nearly all patients are candidates for outpatient surgery.

“There are no good and bad candidates [for outpatient surgery]; they are all good candidates if they are aware before and prepare to go home the same evening,” Sonnery-Cottet said.

Good clinical outcomes

There are many good reasons to perform outpatient orthopaedic surgery, not the least of which is the ability to achieve clinical outcomes comparable to inpatient procedures.

In their single-center series that studied 1,449 consecutive patients, Øystein Helseth and colleagues showed that same-day cervical and lumbar spine surgery is a reasonable treatment option. Nearly all the patients were discharged the same day as their operation. Furthermore, the overall complication rate was 3.5%, surgical mortality was 0% and hospital re-admission within 3 months of surgery was 1.5%, the authors wrote.

Nanne P. Kort, MD, PhD, and colleagues demonstrated similar results in a case-controlled study that examined the clinical outcomes of same-day unicompartmental knee arthroplasty. Of the 20 patients in the outpatient group, 85% were discharged the day of surgery with well-controlled pain.

Outpatient surgery makes good economic sense since inpatient surgery can be a heavy burden for the hospital, according to Robert Pflugmacher, MD, of Bonn, Germany.

Same-day surgery can cut costs not just “for the hospital, but for the whole system,” he said. “Therefore, it will save a lot of money, and I think therefore, the politicians will maybe move it into the right direction.”

Surgical protocols

The operating room set up is the same whether the procedure is inpatient or outpatient, according to Sonnery-Cottet. However, same-day procedures are operated on early in the morning.

“We are able to do eight to 10 ACLs [as] outpatient[s] per day,” Sonnery-Cottet said. “The first patient is operated on at 7:30 a.m. and is usually hospitalized a day before.”

This type of scheduling may improve efficiency and possibly increase income for the hospital. “So [an] early morning case, they will leave around noon,” Verdonk said. “[For] some of these cases, you can actually plan to have the same bed in the same hospital used twice in the same day.”

Sources discussed the importance of anesthesia choice and postoperative pain control.

“Pain is a big issue for patients,” Verdonk said. “Having better pain protocols is increasing the numbers of patients who are able to go home earlier, so the protocols will differ a little bit. We will maximize the pain control for ambulatory surgery, but avoid opioids because they can give depression of breathing.”

Postop observation

All the surgeons interviewed agreed patients should remain at the hospital for a period of postoperative observation. Sonnery-Cottet usually keeps his patients at the hospital for about 4 hours postoperatively.

“It depends on how they are after surgery,” he said. “Before leaving the hospital, all of them are made to stand up and walk by our physiotherapist. It is a good method to assess the patient after surgery.”

Discharge criteria should be clear, joint reconstruction surgeon Henrik Husted, DMSc, PhD, of Copenhagen, said. To be discharged from his clinic, patients undergoing outpatient total knee arthroplasty must have less than 500 mL intraoperative blood loss, be back in the patient ward before 3:00 p.m. and be safely mobilized, he said. In addition, they should display no clinical symptoms of anemia, have pain scores less than 3 points at rest and less than 5 points during activity, Husted said.

He also requires postoperative radiographs prior to discharge.

Whether it is a nurse or the surgeon, someone must contact the patient the day after surgery to answer questions, assess pain relief, etc. For his same-day surgery patients, Vehmeijer himself contacts patients the day after surgery.

“They do not know that I am calling,” Vehmeijer said. “We see them again in the hospital after 2 weeks to look at the wounds. If patients live far away from the hospital, they can go to their general practitioner. After 6 weeks, we will see them in the hospital and take an X-ray, and we see how they are doing.”

Patients must know what to expect before their outpatient procedure. “Front loading [patients] with information is key,” Husted said. “An informed patient is a motivated patient.”

Patients and family members at Husted’s hospital attend a preoperative multidisciplinary seminar hosted by a surgeon, ward nurse, anesthetic nurse and a physiotherapist, to learn the details about the upcoming surgery.

Biggest challenges

Same-day cases require a significant investment in time and planning, Sonnery-Cottet said. Patient safety is also a significant issue when considering moving larger surgeries into the day care setting, according to Verdonk. Whereas postoperative complications such as blood loss, deep vein thrombosis and infections can be managed quickly in the hospital, this may not be the case with same-day surgeries.

Although the complications of outpatient surgery are typical — including early postoperative infection, blood loss and pain — they can be more frightening, Verdonk said.

“When it happens outside the hospital, as a surgeon or as a treating physician, you are never sure if the reaction or the speed of reaction of those people around the patient will be the same as inside the hospital,” he told Orthopaedics Today Europe.

In the 100 same-day cases Vehmeijer has performed since April 2014, he said there have been few complications.

“We had one readmission of a guy we saw 11 days after surgery,” Vehmeijer said. “He had some wound effusion. We hospitalized him for one or 2 days, and then he went home. No surgery had to be performed.”

Other challenges

Obtaining reimbursement for certain same-day procedures can be one of the challenges. In Germany, there are no reimbursement codes for spine procedures. “You do the procedure — the kyphoplasty. You go in the evening to see the patient,” Pflugmacher said. “He is pain free and wants to go home. But you have to keep the patient because the regular process is the patient has to stay the night.”

Reimbursement for these same-day procedures may ultimately be lower, according to Gunnar Flivik, MD, PhD, of Lund, Sweden. “The reimbursement will eventually be less if more patients are sent home the same day, but not least if it is financed by the insurance companies,” he said.

In some regions, cultural views on same-day procedures play a role in deterring its widespread use, according to Flivik. In Scandinavia, for instance, there has not been a tremendous push to switch to same-day cases, at least for arthroplasty patients. Neither the physicians nor the patients can see the actual benefit.

“I am not sure if a hospital system like the one we have in Scandinavia benefits from it on a wider scale,” he said. Most Scandinavian patients go directly home after hospitalization, and not to a nursing home, which is an important distinction from many other European countries.

“The pendulum always goes a bit too far before it settles in the optimal position,” Flivik said. “For arthroplasty patients, I believe a postoperative stay of 1 day to 2 days is optimal for the majority of patients. I think most patients benefit from at least 1 night in hospital.”

Currently, Husted and colleagues are assessing issues like patient selection, safety and satisfaction. At Husted’s institution, they have been using fast-track recovery for 13 years, which has reduced length of stay to 1 day or 2 days while maintaining high patient satisfaction levels.

“Our main question is: Do we want to jeopardize this with speeding this up even more?” Husted said. “If we can do this in 10% to 15% or more of patients, [same-day surgery] will be an option.”

Inappropriate for outpatient setting

Opinions differ on which surgeries should remain inpatient procedures. Revision procedures and complex primary surgeries — such as those required for congenital hip dislocation or severe valgus/varus knees — require some degree of hospitalization, Flivik noted.

Spinal decompression should not be performed as a day-case surgery, according to Pflugmacher.

“In my opinion, it is too much,” he said.

Spine fusion, arthroplasty of the hip, knee, ankle and shoulder, as well as tumor resection, should remain inpatient surgeries, according to Verdonk. “I believe all arthroscopic procedures can be safely done in daycare; however, in my current practice, ligament reconstruction like ACL or PCL, osteotomy stay overnight. Arthroplasty [patients] stay a number of days.”

Outpatient orthopaedic surgery may be the next step in the evolution of the specialty. “We have seen these types of leaps within orthopaedics [before],” Vehmeijer said. “For instance, ACL repair nowadays is an outpatient procedure, but the first report of an outpatient procedure was in 1995. Back then, outpatient ACL repair was thought of as just ridiculous. Nowadays, it is quite normal. I see it as a logical step in the evolvement of orthopaedics, in general, and hip surgery, in particular.” – by Colleen Owens

• References:
• Helseth Ø, et al. Neurosurgery. 2015; doi:10.1227/NEU.0000000000000746.
• Kort NP, et al. Knee Surg Sports Traumatol Arthros. 2015. Epub ahead of print.

• For more information:
• Gunnar Flivik, MD, PhD, can be reached at Lund University, S-221 85 Lund, Sweden; email: gunnar.flivik@med.lu.se.
• Henrik Husted,DMSc, PhD, can be reached at Department of Orthopaedics 333, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark; email: henrik.husted@regionh.dk.
• Robert Plfugmacher, MD, can be reached at Department of Orthopaedics and Trauma Surgery, University Hospital Bonn, Sigmund-Freud-str. 25, 53127 Bonn, Germany; email: robert.pflugmacher@googlemail.com.
• Bertrand Sonnery-Cottet, MD, can be reached at Center Orthopedique Santy, 24 Avenue Paul Santy, 69008 Lyon, France; email: sisocot@aol.com.
• Stephan Vehmeijer, MD, PhD, can be reached at Department of Orthopaedics and Traumatology, Reinier de Graaf Hospital, Delft, The Netherlands; email: s.vehmeijer@rdgg.nl.
• Peter Verdonk, MD, PhD, can be reached at Antwerp Orthopaedic Center, AZ Monica, Harmoniestraat 68, 2018 Antwerp; email: pverdonk@yahoo.com.

Disclosures: Pflugmacher and Flivik report no relevant financial disclosures. Sonnery-Cottet reports he is a consultant for Arthrex. Verdonk reports he is a consultant for DePuy Synthes, Smith & Nephew, Active Implants, Orteq Sports Medicine and Episurf. Husted reports he is a board member of the Rapid Recovery Program for Zimmer Biomet and is a board member of the Lundbeck Foundation for fast-track hip and knee recovery. Vehmeijer reports he is a Rapid Recover advisory board member for Zimmer Biomet.

 

Have national guidelines or regulations for reimbursement affected the ability to perform outpatient orthopaedic surgery?

Goal should be optimal care

Thinking back about how we started with daycare surgery, it was not influenced by any financial aspect. It was done to optimize patient care and try to offer what patients asked for. We only offered it to patients who were fond of the idea.

If you look a little further about reimbursements, in the next few years, we have a lump sum or a standard agreement about how many total knees and total hips we can perform. This covers daycare and regular admissions. The price for the next few years is fixed. Within this period, we can offer care that is preferred by and best for every patient. However, you could imagine that when this period passes, it could be a different case. If insurance companies may try to get a more favorable agreement because we can do it in daycare, we might have a problem. Although with daycare surgery a patient will only stay in the hospital during the day, the effort put into this patient during this day is at least as much as for a patient who stays overnight.

It is not simply a cost reduction, in my opinion, because we put a lot of effort into getting patients up and going within one day. We do a lot more in this single day. You could say the costs of an admission are condensed in daycare. This means the nurses, physiotherapists, nurse practitioners and so on spend more time with these patients with the daycare concept. Furthermore, in the early phase the after-care is intensified compared with regular admissions to allow for adequate and safe care. This has to be taken into account when we negotiate with the insurance companies next time.

At this time, there is no constraint for us and numbers are relatively small compared to regular admissions. Hopefully, in the future as numbers grow, we will be allowed to continue to deliver day-care joint replacement surgery with the necessary ingredients.

Rutger C.I. van Geenen, MD, PhD, is an orthopaedic specialist registrar in Amsterdam.
Disclosure: Van Geenen reports he is a paid consultant to, a paid presenter/speaker for and received research support from Zimmer Biomet and he reports he receives research support from Stryker.

Base surgical decision on medical decisions

In Spain, we have specific guidelines for outpatient surgery. However, in our case the vast majority of surgeries are with hospitalization. We only perform a small amount of outpatient surgeries. Sound medical criteria guide our decisions on this; however, there are economic aspects that can be taken into account.

For the physician, outpatient surgery may generate additional stress, as the postsurgical period is not under hospital control.

For the hospital, outpatient surgery involves optimizing human and material resources, and in a normal shift more outpatient surgeries may be attended to and reduce the unit cost of the surgery, as well as help allocate resources for other surgeries of greater importance.

For the patient, this can make the importance of outpatient surgery less relevant, but from the economic point of view, hospital costs decrease.

For the insurance company, reimbursement of hospital costs is reduced in outpatient surgery, and this allows for the tendency to undervalue medical fees paid for such work.

For public health services, outpatient surgery is a way to optimize resources at all levels.

The decision for or against outpatient surgery should be subject to sound medical judgment, placing value on good medical practice and considering the specific requirements of each individual patient.

Ramon Cugat, MD, PhD, is at Hospital Quiron Barcelona, in Barcelona, and is an Orthopaedics Today Europe Editorial Board member.
Disclosure: Cugat reports no relevant financial disclosures.