The outpatient migration: key thoughts for joint replacement and spine

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Between 2016 and 2021, the Advisory Board forecasts 23 percent growth in outpatient surgery while over the same time period projecting inpatient surgery growth of 1 percent.

Over the same time period, outpatient joint replacements are expected to grow 173 percent, compared to 6 percent for inpatient joint replacements.

This presents major opportunities for cost reductions, while optimizing the patient and physician experience. Total joint arthroplasty and spine surgery are both attractive targets, with double- and triple-digit growth expected in outpatient services.

At Becker's 17th Annual Future of Spine + The Spine, Orthopedic and Pain Management-Driven ASC Conference in Chicago, Surgical Care Affiliates and Pacira BioSciences hosted a workshop focused on migrating high-acuity cases to ASCs. A panel of experts from Pacira outlined best practices for patient selection, optimization and program management.

Optimizing the outpatient setting

When it comes to total joint and spine procedures, ambulatory surgery centers offer many benefits. Patients like the concierge feeling and are attracted to lower fees for the same services at ASCs. "The facility fee for a joint replacement at an ASC is around two-thirds of the cost of a hospital. This drives patient satisfaction," said Robert Mayle, Jr., MD, an orthopedic surgeon based in San Francisco and affiliated with Sutter Health in Sacramento. Physicians also appreciate that they can handle more cases with greater flexibility. Dr. Mayle said, "ASCs are a 'happy place' for total joint surgeons. The staff are motivated and responsive to our equipment needs."

Although many patients would prefer ASCs over traditional inpatient stays, not every patient is a good candidate for the outpatient setting. Patient selection criteria are essential. "With spines, we want to find the correct patient who will be medically safe in an outpatient setting and will do well," said Michael Briseno, MD, a partner and medical director with Texas Health Orthopedic Surgery Center Heritage in Fort Worth.

For outpatient total joint and spine procedures, patients must meet a variety of predetermined preoperative criteria. Both the surgeon and the anesthesiologist must feel comfortable treating the patient. Staff examine each patient's medical history for conditions like stomach infections and sleep apnea. They also consider social factors such as the patient's motivation, level of functional independence and access to an engaged caregiver.

"Sometimes it comes down to simple judgment," said Dr. Briseno. "A patient with a history of opioid dependency isn't going to do well if they are released from an ASC 23 hours after surgery. We want to be conservative."

The medications used throughout the episode of care must align with the ASC program's goals. According to Dr. Mayle, "Using preoperative, perioperative and postoperative medications is vital, especially with the spine. It's something that's often missed in the inpatient setting which is a recipe for a long hospital stay. That’s not what we want."

Before transitioning a total joint program to the ASC, Amit Mirchandani, MD, medical director of Texas Health Surgery Center Rockwall, stress tested the program in an inpatient setting. This enabled him to observe patients for more than 23 hours if necessary. At the preoperative level, Dr. Mirchandani administers medications to address pain pathways from the periphery to the brain. For total joints, low-dose spinal anesthesia is an important intraoperative innovation to decrease postoperative narcotic use and improves early mobility.

Best practices for developing successful ASC programs

Successful ASC programs are managed holistically. The panel highlighted several best practices:

  • Surgeons and anesthesiologists work as a team. "Anesthesia, surgery and the staff must have common goals about the safety profile and patient selection criteria, as well as practices to minimize narcotic use, improve early mobility and get patients back home safely," said Dr. Mirchandani.
  • Expectations must be set with both patients and staff. Surgeons must prepare patients for what to expect. If procedures don't go according to plan, staff must also understand what actions to take. Dr. Briseno noted, "[Anterior cervical discectomy and fusions] are a routine surgery. But they have one large potential complication. We train staff to recognize airway issues and manage them."
  • Plan for success. Patient criteria are guidelines, but teams must also exercise judgment if they think someone isn't a good candidate. "If you're starting out with spine surgeries in the ASC, it's important to optimize for success. If you fail right off the bat, you will doubt yourself and the nursing staff will also doubt what you're doing," said Dr. Mayle.


Thanks to the evolution of surgical techniques, many large cases including total joint and spine procedures can now be handled in the outpatient setting. The keys to safe ASC experiences, however, are patient selection criteria and checkpoints for pre-surgical optimization.


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