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Should CMS remove hip arthroplasty from the inpatient-only list?
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Patients, surgeons should make an informed choice
This is a complex issue with implications for multiple stakeholders and patient safety, and well-being should be squarely at the core of the answer. Although younger and healthier patients are most appropriate for outpatient total hip arthroplasty, we should ask whether patients aged 65 years or older are able to undergo outpatient, same-day discharge THA safely if they are otherwise healthy and active. Fortunately, there are data to guide the decision-making.
Courtney and colleagues queried the National Surgical Quality Improvement Program database on 49,136 Medicare patients who underwent total knee arthroplasty. They found outpatient, same-day surgery was safe in a subset of patients older than 65 years with minimal medical comorbidities. In a report on the medically based Outpatient Arthroplasty Risk Assessment Score, of which age is not a component, outpatient THA and TKA procedures were performed successfully with a 1.8% readmission rate. Collaboratively, the American Association of Hip and Knee Surgeons, AAOS, Hip Society and Knee Society recently released a position statement on outpatient hip and knee surgery, which emphasizes patient safety through optimized protocols and pathways, as well as proper patient selection without specifically commenting on patient age.
Given the potentially enormous cost savings to the health care system, it is appropriate for CMS to remove THA from the inpatient-only list and allow patients and surgeons to make an informed choice. Select motivated patients older than 65 years with negligible medical comorbidities and adequate home support may undergo THA as an outpatient safely.
- References:
- Courtney PM, et al. J Arthroplasty. 2018;doi:10.1016/j.arth.2018.01.003.
- Meneghini R, et al. J Arthroplasty. 2018;doi:10.1016/j.arth.2018.10.029.
- Ziemba-Davis M, et al. J Arthroplasty. 2019;doi:10.1016/j.arth.2019.01.007.
R. Michael Meneghini, MD, who is director of the Indiana University Health Hip and Knee Center in Indianapolis, is an Orthopedics Today Editorial Board Member.
Disclosure: Meneghini reports he receives licensing fees from DJO and has ownership in an ASC.
THA should remain on inpatient-only list
THA is one of the successful operations in all of medicine and is often described as the operation of the 20th century.
Further advancement of the operation is related to improved implant material, less invasive surgery, better management of perioperative pain and other factors. The improvements have led to a shortened hospitalization and most patients go directly home. It is of interest that Medicare data include a modest number of patients coded as outpatient, but few going home the same day. Is it necessary to change inpatient THA to outpatient THA for a small percent of Medicare patients?
The confusion and the unintended consequence when CMS removed TKA from the inpatient-only list should not be repeated in THA. Although CMS did not intend to pressure surgeons to do outpatient TKA, many did, and when patients were unstable to go home, their status was changed to inpatient.
Until we have more evidence to determine who are the candidates for a safe, outpatient THA and know what support is required for patients’ safety while at home, THA should remain as an inpatient procedure. Shreyasi Deb, PhD, MBA, the senior manager of health policy in the AAOS Office of Government Relations, wrote in March 2019, “We requested that CMS direct Medicare’s Beneficiary and Family Centered Care Quality Improvement Organizations to consider our guidance regarding patient selection and socioeconomic risk factors in their hospital billing reviews to protect beneficiaries from unnecessary risk.”
THA should remain on the inpatient procedure list. If patients recover quickly and are ready to be discharged home before the 2 midnights, then they should be permitted to go home without penalty to them or the hospital providing their care.
- Reference:
- Deb S. New guidance attempts to resolve confusion regarding the removal of TKA from IPO list. Available at: www.aaos.org/AAOSNow/2019/Mar/Cover/cover02/. Accessed March 27, 2019.
Kevin L. Garvin, MD, is the L. Thomas Hood, MD, professor and chair in the department of orthopaedic surgery at University of Nebraska Medical Center.
Disclosure: Garvin reports no relevant financial disclosures.