This post was co-authored by Grace McClure and Dr. Nicholas Frisch), M.D, OS.
Whether or not you like the idea of it, outpatient joint replacement surgery, also known as “same-day” or “ambulatory” joint replacement surgery, is on the rise across the US. Year over year, more and more patients are having their hips or knees replaced outside of the traditional hospital setting with less time spent under a care team’s watchful eye.
In fact, between 2012 to 2015, there was a 47% increase in elective outpatient hip and knee replacement procedures. Over the next decade the number of patients having same day hip replacement surgery and same day knee replacement surgery is expected to skyrocket.
Over the next 10 years in the US, outpatient knee replacements are expected to increase by 457% and outpatient hip replacements by 633% In other words, experts predict that by 2027 more than 50% of joint replacements will be performed in an outpatient setting.
So why the major shift in how hip and knees are being replaced? What are the differences between inpatient and outpatient surgery? What are the benefits? If given the choice, should you opt for an outpatient joint replacement?
Read on as we answer these questions and more. Let’s talk same day surgery basics and get you up to speed with the future of joint replacement surgery.
What is Outpatient/ Same-Day Joint Replacement?
If we know that outpatient joint replacement surgery is synonymous with same day joint replacement surgery, then we’ve pretty well got a working definition. With outpatient or same day joint replacement surgery, patients are geared up to go home on–you guessed it–the same day. Outpatient joint surgery is performed in a special hospital unit or outpatient (ambulatory) care center. The admission, procedure, and discharge all happens in less than 24 hours.
A study measuring discharge times for outpatient surgery found that the “average time from admission to discharge was 375 minutes in the THA [total hip arthroplasty/ total hip replacement outpatient surgery] group, 426 minutes in the TKA [total knee arthroplasty] group, and 371 minutes in the UKA [unicompartmental knee arthroplasty] group.” This means that the total knee replacement group, spending just over 7 hours admitted to an outpatient center, had the longest episode length. This is still a fraction of the average hospital stay for inpatient joint surgery.
For some patients, same day surgery can feel too rushed. This is understandable. However, your care team will only move forward with an outpatient surgery if they think you can handle the quick turnaround. If you think you can benefit from a same-day surgery and your care team signs off, they will help you mentally and physically prep for less hospital time.
Why is Total Outpatient Joint Arthroplasty Gaining Popularity?
Same-day discharge from any surgery, let alone an invasive procedure like a joint replacement, wasn’t always possible. A lot of things and have had to come together to make outpatient joint surgery the growing, possible trend it is today. In order for patients to be able to go home on the same day as a surgery, advancements had to develop to the techniques, patient education, patient pre-op preparation, discharge process, the way anesthesia is administered, and so forth.
The advancements in joint replacement surgery paired with factors like average patient age decreasing and patient health improving, have led to shorter and shorter hospitalizations over the years.
Outpatient joint replacement surgery, although a large leap from the average 2 night stay during an inpatient replacement, is a natural progression for the procedure. In saying this, an outpatient surgery is not for everyone. For outpatient surgery to be successful the stage must be set with a myriad of key factors coming together.
5 Key Factors for Outpatient Success
- Engaged, Healthy Patients: Patients should be carefully selected. Outpatient surgery may only be right for patients who are in good overall health, do not have secondary conditions or added risks, are a healthy body weight, and younger in age.
- An At-Home Support System: Those recovering entirely at home will need to rely on a dedicated joint replacement caretaker, also called a “coach”. This support person may be a family member or friend, but should be someone who is committed to patient recovery, attends pre-op meetings, is present during discharge etc.
- Comprehensive Pre-op Health Optimization and Preparation: The patient should be engaged in a formal PreHab program to mentally, physically, and environmentally prepare for surgery. Patients who are physically prepared before surgery mobilize faster after the procedure and are ahead in physical therapy rehab. Being health-optimized and prepared for surgery means that a patient has a head start on recovery and is prepared to recover without the in-person, day-to-day guidance of their care team.
- Improved Surgical Techniques: Advanced surgical techniques, like minimally invasive surgery or robotic arm-assisted surgery limit muscle damage and blood loss. This reduces the need for blood transfusions while smaller incisions can cut down risk of infection and heal faster. Advancements to the way the surgery is performed has really set the stage, making outpatient possible.
- Better Pain Management & Anesthesia Techniques: With post-op pain being moderate to debilitating, the code had to be cracked to make adequate at-home pain control possible. More efficient pain plans paired with regional or local anesthetic (avoiding general anesthesia and the longer recovery that follows) means that patients can be discharged sooner.
What are the Differences Between Same-Day and Inpatient?
Although both inpatient and outpatient joint replacement surgery results in a new, sparkly prosthetic hip or knee, the process looks a little different. Each carry with them some pros and cons, which may make one type more suitable or appealing to a patient than the other.
Read on as we break down the pros and cons to same-day joint replacement surgery and in-hospital surgery.
Same-Day Joint Replacement
- Flexible, innovative care. Outpatient facilities tend to be newer, with forward-thinking surgeons using cutting-edge techniques that allow for early discharge.
- Cheaper for patients and providers. If full insurance coverage is an issue, having a joint replacement at an outpatient center is significantly cheaper. In a study published in Orthopedic Journal of Sport Medicine, outpatient joint replacement charges were found to be “an average of $20,573 less per patient than the inpatient average charge of $46,845”.
- Greater patient satisfaction. Outpatient joint replacement recipients report being more satisfied with the care they’ve received and their overall replacement. As reported by Ortho Illinois, “patients and their families consistently rate their experience as more pleasant at an outpatient surgery center.”
- Improved surgery outcomes and recovery. Studies show that blood transfusions are lower, infections can be reduced, and that patient groups that have outpatient surgery can recover faster at home.
- Shorter stay in hospital. A shorter stay at a medical center comes with a host of benefits including a lower risk of hospital-acquired infection (like MRSP) and greater comfortability being able to recovery immediately after surgery in your own, comfortable space.
A study comparing outpatient versus inpatient partial knee replacement surgery, states that “studies have shown increased patient satisfaction and improved outcomes with an accelerated recovery protocol and decreased length of hospital stay”.
- Not for everyone. Some patient who are interested in an outpatient procedure may not be a candidate. Since hospital-stay is drastically reduced, only low-risk patients who are healthy and have at-home support are considered.
Dr. Frisch explains, “it is important to realize that not everyone is a candidate for outpatient surgery and it’s important to discuss this with your surgeon. If you are a candidate, then you should understand that in order to have a the best outcome, to preparation starts well before you ever set foot in the hospital or surgery center. The use of programs such as PeerWell starts once you decide on surgery and will follow you through the entire process to ensure you have the tools necessary to maximize your results.”
- Not as widely available. Depending on your location, an outpatient surgery may not be available in your area. Although more ambulatory centers are in cropping up in more rural areas, according to the Ambulatory Surgery Center Association, there were only 40 outpatient centers in the US performing outpatient joint replacements in 2014.
- Less support from care team. For some, same day surgery can feel too rushed and overwhelming. An outpatient surgery does not offer as much hand-holding and care-taking after surgery. Although outpatient care teams will reach out for regular phone calls and coordinate daily in-house physical therapy right after surgery, it’s not the same as being in-hospital and getting around-the-clock care in the first days of recovery.
- Need to coordinate at-home support. While this may be preferred for some patients, you will need to have family or friends care for you immediately after surgery as you won’t have nurses and doctors on standby at home. You will need to organize a caretaker to support you in the days that follow surgery.
Inpatient Joint Replacement
- Catch-all for everyone. An inpatient joint replacement is suitable for everyone that has been recommended the procedure by their primary physician and orthopedic surgeon. If you’ve been cleared for surgery, you are a candidate for a traditional, in-hospital hip or knee replacement.
- More hospital and surgeon selection. Being the most popular method of joint replacement surgery, the most reputable surgeons and hospitals across the country offer inpatient replacements. This gives you more opportunity to choose the right surgeon and orthopaedic hospital for you.
- Greater support. Although you will still require at-home support for when you are discharged, recovering for a longer period of time in the hospital means constant monitoring and care. For those with secondary health conditions or added risk, this may be necessary for your health and safety.
- More costly. An inpatient joint replacement can cost more than double what an outpatient joint replacement costs. In fact, “the average cost savings of 17.6% to 57.6% for outpatient procedures relative to similar procedures performed in a hospital”. If your insurance coverage isn’t as comprehensive, you may have to pay out of pocket for the extra expenses.
- Greater risk of infection. The longer you spend in hospital, the greater the chance of getting a hospital-acquired infection. Although infection risks are low, the infection-rate of your selected hospital should be taken into account. You want your hospital to be at or below national averages for infection rates. Look up your hospital infection rates here.
- More challenging pain management. This one is up for debate, but some patients have reported slightly higher post-op pain upon discharge after a same-day surgery. This could be because for ambulatory patients, pain treatments have been predetermined before discharge and aren’t adapting as your care team sees fit.
The main difference between same-day surgery and inpatient surgery is the level of preparedness required. We firmly believe that preoperative education and the active preparation of your body, mind and environment leads to a better outcome and a safer, faster recovery. However, this kind of surgery prep is not passive. In order to be really experience the benefits of an outpatient joint surgery, putting in the leg work to understand the procedure and get ready for it is vital.
If you’re considering joint replacement surgery, Join PeerWell. We will match you with a surgeon that offers PeerWell PreHab for free PreHab gets you totally ready for your joint replacement–whether it’s performed in a hospital with an overnight stay or done same-day with recovery completely at home.
From a physicians perspective: Perioperative optimization is critical to the success of outpatient joint replacement. We believe that the amount of time and effort put in on the front end, before ever receiving your new joint is as important as anything that happens after. Appropriate optimization both medically and personally can have an incredibly positive impact on your overall experience and outcome.
Dr. Nicholas Frisch, M.D., OS, MBA is an award-winning orthopedic surgeon based out of Rochester, Michigan. He focuses on minimally invasive joint replacement surgery and complex revisions. Dr. Frisch completed his residency at Henry Ford Hospital in Detroit and his Adult Reconstruction Fellowship at Rush University Medical Center in Chicago. Dr. Frisch is has won Orthopedics Best Clinical Article Award, the AAHKS Healthcare Policy Fellowship, Outstanding Resident Award Henry Ford Hospital, the Ford Motor Co. Connected Health Challenge, and more.