The safety and success of outpatient total joint arthroplasty (TJA) depend on establishing a multidisciplinary total joint program that requires a team approach. Appropriate patient selection is the most important aspect for performing outpatient TJA successfully. One of the biggest advancements that has led to shorter hospital stays and created the potential for same-day discharge was the development of multimodal pain management protocols. Though most outpatient TJAs are performed on the lower extremity, shoulder arthroplasty may be better suited for the outpatient setting because it is not a weight-bearing joint and has a history of shorter hospital stays, decreased mortality rate, less blood loss, and fewer complications than hip and knee arthroplasty. A growing body of knowledge is demonstrating that outpatient total shoulder arthroplasty (TSA) can be safely performed while significantly reducing costs.

Outpatient TJA offers a unique case study for the implementation of value-based health care. The large case volumes associated with TJA allow a more objective comparison of outcomes and cost differences than in many other areas of orthopaedic surgery. Over the past decade there has been a significant shift in TJA from a traditionally inpatient procedure to an outpatient procedure. Some projections show that outpatient TJA is expected to increase by more than 450% over the next decade, with estimates that by 2026 more than half of all TJAs will be performed as an outpatient procedure.¹

In 1965, health care was transformed with the introduction of Medicare and Medicaid. In 2010, the Patient Protection and Affordable Care Act (ACA) was signed into law, driving significant changes to health policy.² The ACA enacted major reforms,
broadening coverage through subsidized private insurance programs and incentivizing the adoption of a model where health care providers reduce costs through value-based reimbursement.³ Specifically, the transition to “value-based care” can be defined as delivering the highest quality care at the lowest possible cost.³ To achieve this goal, the ACA mandated that a certain percentage of payments from the Centers for Medicare & Medicaid Services (CMS) be tied to value-based initiatives. Bundled payment programs such as the Bundled Payments for Care Improvement (BPCI) and the Comprehensive Care for Joint Replacement (CJR) were created to accomplish this goal.⁴,⁵ These programs primarily target lower extremity joint arthroplasties, a significant portion of CMS expenditures. In 2014, Medicare patients underwent 400,000 lower extremity joint arthroplasties at a health care cost of $7 billion.⁵

As a response to the cost pressures generated by the ACA, surgeons have investigated the possibility of realizing cost savings by moving TJA from the traditional hospital setting to the outpatient environment; this can be done either by same-day discharge from a hospital or by moving the surgical setting to an ambulatory surgery center (ASC). The hip and knee literature has emphasized this difference. Aynardi et al⁶ demonstrated a cost savings of $6,798 for outpatient total hip arthroplasty (THA) compared with their inpatient cohort. Another study by Lovald et al⁷ showed that 2-year costs of the outpatient total knee arthroplasty (TKA) group were $8,527 less than those for the inpatient group.

The cost savings have been further amplified by alternative payment models such as BPCI and CJR. These programs have been designed to maximize value without sacrificing quality of care by incentivizing hospitals and surgeons to reduce unnecessary expenditures and penalizing or rewarding them based on performance.⁸ The early results of these programs have been promising with inpatient procedures; however, the results with outpatient arthroplasty are still pending.⁹

Despite the cost savings, to truly create value with outpatient arthroplasty, surgeons must do so without increasing patient risk or compromising outcomes. The outpatient program should be focused on minimizing complications and maximizing patient safety, followed by decreasing costs. Fortunately, advancements in surgical technique, pain management, and blood loss and recovery protocols have helped make this possible. Recent literature has shown that outpatient TJA is a safe alternative to hospital admission for the appropriate patients.¹⁰,¹¹ Greenky et al¹² reported on Medicare patients undergoing THA and found that outpatient procedures had lower 30-day complication and readmission rates in comparison with inpatient procedures.¹² Similar studies have shown a decrease or no difference in complication and readmission rates with outpatient TKA and TSA as well.¹⁰,¹³ Although complications have been minimized, patient outcomes have still been maintained. A review by Lovett-Carter et al¹⁴ noted that patient-reported outcomes for outpatient THA were high, and 96% were satisfied with the decision to undergo outpatient surgery.¹⁴

The safety and success of outpatient arthroplasty depends on establishing a multidisciplinary total joint program that requires a team approach. The entire process, including the initial patient encounter, preoperative testing and medical
clearance, anesthesia, surgical care, postoperative nursing, and rehabilitation, relies on the development of robust pathways and processes to ensure success. The American Association of Hip and Knee Surgeons recognized six essential elements that require optimization for a successful outpatient arthroplasty program: patient selection, patient education and expectation management, social support, clinical and surgical team expertise, surgery center factors, and evidence-based protocols and pathways.¹⁵

Appropriate patient selection is the most important aspect for performing outpatient TJA successfully and cannot be overemphasized. Choosing the appropriate patient avoids placing undue risk on the patient in the ambulatory surgery setting or in their own home after surgery. In general, patients should be relatively healthy with few medical comorbidities, independent with adequate social support, and with relatively straightforward pathology to minimize additional surgical time or surgical insult to the patient. For example, difficult revision cases with complex pathology requiring significantly increased surgical resources and time are best performed in the inpatient setting. Medical evaluation from a primary care provider and cardiac and/or pulmonary workup, if appropriate, is critical to avoid unexpected medical complications. Development of and adherence to patient selection protocols allow reliable identification of optimal surgical candidates and those more at risk for medical complications or adverse surgical outcomes that would benefit more from inpatient care. Various scoring systems and patient selection algorithms have been proposed to accomplish this goal.¹⁶,¹⁷,¹⁸ Fournier et al¹⁹ described an algorithm for identifying appropriate candidates for outpatient total shoulder arthroplasty. Based on this algorithm (Figure 1), patient age and preoperative hematocrit can be used for initial screening, followed by a thorough workup and evaluation for pulmonary or cardiac conditions, and finally a history of thromboembolic disease and anticoagulation. Using this algorithm resulted in a low incidence of complications and no hospital admissions.

The next important aspect of an outpatient arthroplasty program is detailed patient and family education. Preoperative education is needed to outline the expectations and environment for a successful recovery postoperatively upon discharge from the hospital. After discharge, patients should have adequate support available and clear and rapid paths of access to team members of the total arthroplasty program to answer questions and address concerns that arise until they have sufficiently recovered from surgery.¹⁵ Thorough education before surgery can decrease patient anxiety about same-day discharge and recovery postoperatively, and help predict any potential problems/may decrease prolonged stays or hospital admissions postoperatively.¹⁶

The medical and surgical team should be experienced in TJA and should preferably demonstrate successful same-day discharge in the hospital prior to making the transition to the ASC setting. The anesthesia team and recovery room staff should be involved in the development and implementation of rapid recovery protocols and pain pathways to ensure a safe and expeditious recovery from anesthesia. Because studies have shown the benefits of early ambulation and early physical therapy following TJA,²⁰ a physical therapist or appropriately trained team member should work with the patient postoperatively and determine their
safety for discharge home from an independence and mobility standpoint. Before discharge, arrangements should also be made for early outpatient physical and/or occupational therapy. The facility also should be adequately equipped to ensure patient safety throughout the procedure and recovery. If a patient is not appropriate for same-day discharge home postoperatively, the facility and staff should be equipped for an overnight stay or transfer to a hospital must be arranged to ensure the patient’s safety is maintained. Many ASCs have the capability to observe patients for 23 hours after surgery, but the nursing and other resources necessary for an overnight stay should be put in place before an outpatient TJA program is begun.

ASCs that traditionally perform outpatient-only procedures may not be appropriately equipped, initially, for TJA. Surgery center facilities may have limited storage and sterilization resources. Because TJA is more instrument specific and equipment intensive than traditional outpatient surgeries, a thorough inventory of all equipment needed to perform TJA should be compiled and made available.¹⁷ Although sophisticated inventory management systems are not absolutely necessary, they can assist with monitoring disparate arthroplasty systems and implants. Backup instruments should be available to avoid prolonged anesthesia if a critical
instrument is dropped from the sterile field. Case planning and templating preoperatively are useful to ensure appropriate implants and sizes are available. This planning also can improve intraoperative decision making and surgical time, as well as decrease sterile processing department utilization and costs. Intraoperative complications should be anticipated, and equipment should be available to address such issues if they arise. All of these measures help maximize operational efficiency to optimize a facility’s success with outpatient TJA. Additionally, careful attention to room utilization and average surgical times by individual surgeons to make most efficient use of available operating room space is recommended.

The development of evidence-based protocols has been critical to the transition to outpatient arthroplasty.²¹,²² These pathways have standardized and improved recovery and safety following TJA.²²,²³,²⁴ One of the biggest advancements that has led to shorter hospital stays and created the potential for same-day discharge is the development of multimodal pain management protocols. Wall²⁵ first coined the term multimodal pain management in 1988, and described the use of multiple techniques to achieve pain control. Since that time multimodal pain management has developed into a system of using both pharmacologic and nonpharmacologic methods preoperatively, intraoperatively, and postoperatively to control pain.²⁶ These protocols have led to improved pain control and decreased the need for intravenous pain medication, which in turn have shortened hospital stays and opened the door for same-day discharge.²⁷ Use of multimodal pain management has also been shown to decrease opioid requirements postoperatively,²⁸ and recent shoulder literature has shown successful pain control with an opioid-sparing pathway.²⁹ Table 1 demonstrates one suggested multimodal pain management protocol.

One of the leading complications following outpatient TJA is blood loss requiring a transfusion.¹² Because ASCs do not have immediate transfusion capabilities, this is a costly complication that requires transfer to a hospital for infusion of blood products and potential admission for monitoring. One of the greatest effects on decreasing blood loss in outpatient TJA has come from the adoption of the antifibrinolytic drug tranexamic acid. Tranexamic acid has consistently demonstrated its ability to decrease intraoperative blood loss and the need for blood transfusions and is a critical component to safely performing arthroplasty in the outpatient setting.³⁰,³¹ Traditionally given intravenously or topically, recent studies have shown equivalent efficacy with oral preparations and at a fraction of the cost.³¹,³²,³³ In addition to tranexamic acid, the use of bipolar sealer in THA has shown significant benefits at safely limiting blood loss without increasing costs.³⁴,³⁵,³⁶