Make the case for outpatient total shoulder arthroplasty
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Shoulder replacement is an ideal procedure for the ASC environment. During the last 10 years, an increasing number of total shoulder arthroplasty procedures have transitioned from hospital ORs to the more streamlined ASCs.
Find the right patients
Despite initial reservations, patient acceptance and preference of ASC-based shoulder replacement has significantly increased. This transition has been facilitated with the approval of many private payers more than 10 years ago. CMS moved slowly in this direction, despite early data demonstrating the safety of outpatient shoulder arthroplasty. The pace began to change a few years ago, and then the COVID-19 pandemic arrived. Many patients did not relish the thought of spending the night in a hospital and leaped at the chance to go to an ASC instead.
The COVID-19 pandemic led to legislative and administrative adaptations to accommodate the surgical care of patients outside of hospitals, expanding the indications for ASC procedures. By working closely with our anesthesia colleagues to refine patient safety protocols, age limits increased or were removed, and expanded management of previously disqualifying comorbidities significantly increased ASC eligibility.
Evidence has shown that outpatient surgery presents low stress to a patient’s physiology and is safe for a wider range of patients than previously thought. Through evidence-based research, orthopedic surgeons can better identify the patients who are most suitable for outpatient surgery in an ASC.
Optimize perioperative protocols
Recent innovations in perioperative management have opened ASCs to a wider range of patients who need TSAs. One of the most critical innovations to outpatient surgery is better preoperative and postoperative pain control, minimizing the use of narcotics. Multimodal pain treatment combines various groups of pain medications to provide patients with pain relief, resulting in the most effective pain management possible.
Ultrasound-guided regional nerve blocks routinely eliminate perioperative pain on the day of surgery. Less commonly used are interscalene catheters that have the potential to provide up to 3 days of pain relief, but require more attention and monitoring by the patient and the anesthesia service.
The multimodal approach has inspired some orthopedic surgeons to move toward the complete elimination of opioids for postoperative pain management after outpatient shoulder procedures, including shoulder arthroplasty. Additional innovations include enhanced recovery after surgery (ERAS) protocols, which involve preoperative counseling, nutrition optimization, anesthetic regimens minimizing opioids, standardized analgesics and early mobilization. When used together, the protocols ensure patients who are treated in ASCs receive the best care to achieve optimal recovery.
Efficiently reduce complications
Dedicated education and training of the surgical and nursing staff, coupled with comprehensive education for any staff member who has contact with the patient, is fundamental to establishing the most efficient, safe and successful patient journey at the ASC. When an orthopedic surgeon leads a team that is familiar with each other and the procedure, they work together to perform the most efficient procedures possible, which reduces intraoperative and postoperative complications.
Preoperative planning has always been critical to efficiency in the OR. The philosophy of the surgical team should be that the only activity that occurs in the OR is the procedure itself, moving regional blocks to the anesthesia holding area, and ensuring each case is templated to include surgical approach and implant choice when the patient is brought into the OR. A customized surgery can be planned for each patient, which reduces intraoperative decisions and shortens time under anesthesia. Improved consistency at exposing the shoulder joint, minimizing bleeding with precise dissection and the use of IV tranexamic acid, and avoiding injury to healthy structures combined with smaller implants and rapid press-fit fixation results in reduced time under anesthesia. Shoulder replacements should routinely take less than 2 hours, which is the point at which evidence-based studies have demonstrated an increase in adverse outcomes.
Further considerations to increase efficiency and reduce complications include the development of well-documented clinical care pathways that use evidence-based medicine to standardize ERAS protocols, infection control, thrombosis prophylaxis, dressing and brace application, and postoperative instructions among all surgeons who perform shoulder arthroplasty at the ASC. The incorporation of digital technology can provide a real-time assessment of a patient’s journey through the ASC, which allows team members to anticipate the next task necessary to complete the patient’s surgical journey. In addition, digital documentation can provide immediate completion of patient records and submission of charges to the revenue cycle management team on the day of surgery, expediting the completion of surgeon and ASC-based requirements for reimbursement.
Advocate for better economics
As we transition more TSAs to ASCs, with a goal of 80% of all primary shoulder arthroplasty cases, there needs to be a full alignment of patient satisfaction, high-quality perioperative care, surgeon preferences and efficient workflows. Despite this alignment with economic efficiency, reimbursement remains a contentious issue.
As of Jan. 1, CMS has approved primary shoulder replacements to be performed in an ASC environment. CMS reimbursement rates are reasonable for most ASCs, encouraging the shift of site of service from the hospital to the ASC for appropriate patients. When compared with the cost of hip and knee arthroplasty, the significant outlier for shoulder arthroplasty is the expense of the implants, which may be double that of lower extremity implants.
For payers and employer-sponsored health plans, ASCs are the preferred environment for shoulder replacement for healthy patients. Now, the same is true for Medicare patients, especially with Medicare Advantage programs where the financial risk for overall patient populations is managed. Revising payer contracts, incorporating the surgeons in the revenue cycle process and establishing shared savings programs with Medicare Advantage plans are essential to address economic challenges.
The case for taking healthy patients to the ASC for shoulder replacements epitomizes value-based care, delivering similar or better outcomes at a reduced cost. Federal endorsement of the practice for Medicare patients is a commendable step forward, allowing us to increase our opportunity to perform TSAs in the ASC, which is associated with the highest satisfaction among patients and orthopedic surgeons.
- References:
- Basques BA, et al. Bone Joint J. 2017;doi:10.1302/0301-620X.99B7.
- Charles MD, et al. J Shoulder Elbow Surg. 2019;doi:10.1016/j.jse.2019.04.006.
- Erickson BJ, et al. J Shoulder Elbow Surg. 2020;doi:10.1016/j.jse.2019.10.023.
- Faisal H, et al. J Orthop. 2023;doi:10.1007/s43465-023-00867.
- Leroux TS, et al. JSES Open Access. 2018;doi:10.1016/j.jses.2017.
- MacLean IS, et al. Orthopedics. 2022;doi:10.3928/01477447-20211101-09.
- For more information:
- Anthony A. Romeo, MD, is the Chief Medical Editor of Healio | Orthopedics Today. He can be reached at Healio, 6900 Grove Road, Thorofare, NJ 08086; email: orthopedics@healio.com.
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