Patient Selection Drives Total Joints

The more detailed and comprehensive the selection criteria, the better your outcomes are likely to be, which is why facility leaders such as Mr. DeConciliis strongly encourage the use of a standardized screening program — such as the Risk Assessment and Prediction Tool (osmag.net/3gB69RK) — to help guide the process. The form includes a series of questions that help providers determine how well joint replacement patients will respond to surgery and where they'll likely need to be discharged (to a rehab facility or directly home) to recover.

"When it comes to patient selection, you have to focus on health and BMI," says Dr. Meyer. At TCO, that means any patient scheduled to undergo an outpatient joint replacement must have a BMI of 40 or below and diabetics must have a hemoglobin A1C level of less than 7.5 g/dl. Patients with untreated obstructed sleep apnea (OSA) or patients with a STOP-BANG score greater than four who haven't had their OSA treated do not meet the program's inclusion criteria. TCO providers refer to an algorithm to determine if patients with histories of blood clotting, DVT and pulmonary embolism are appropriate candidates for surgery. They also optimize the preoperative care of patients with histories of heart attacks, stent placements, atrial fibrillation and hypertension. Patients with pacemakers are not eligible to undergo surgery. Additionally, patients who have received a steroid injection in the surgical joint within three months of surgery are excluded from consideration.

Mr. DeConciliis uses similar criteria to weed out problematic and potentially unfit candidates. For instance, patients who have their joints replaced at Boston Out-Patient Surgical Suites have BMIs less than 35, an ASA score of 1 or 2 with minimal comorbidities, a hemoglobin level below 7.5 g/dl, and an absence of clotting disorders or anemia. The facility typically doesn't schedule procedures for patients over 70 years old, although Mr. DeConciliis is quick to point out there are exceptions to this age limit. This is key when you consider that, between total knees last year and total hips this year, Medicare is expanding reimbursements for outpatient total joints.

While health factors are a critical component of the patient selection process, they don't tell the whole story. You need to look at the patient's fitness level, as well as their motivation and support system for when they return home to recover. That's where your screening process really comes into play. You have to spend time understanding patients' needs, motivations and obstacles that might hinder their ultimate success in recovery.

ASCs have success with outpatient total joints because they’ve done an excellent job at screening candidates for surgery.
— Gregory P. DeConciliis, PA-C, CASC

TCO nurses spend up to three hours with potential patients discussing health, motivation and home-support issues that might hold them back from achieving a successful outcome, says Dr. Meyer. These potential issues aren't always cut-and-dried. For instance, over-motivated patients can pose just as much of a problem as unmotivated individuals. Dr. Meyer says patients who buy into the care plan do well. But, he adds, problems can arise if they do too little or too much.

Identifying appropriate candidates for total joint procedures should be an ever-evolving process. As your program grows, you may be able to expand your criteria to capture additional cases. Conversely, you might need to take a more conservative approach. The only way to know for certain is to track outcomes data, according to Dr. Meyer. "That information is key to your program's success," he says. "You have to assess it objectively."

TCO's staff analyzes metrics such as post-op infections, hospital readmissions and revision rates at least once per quarter, and adjusts the program's protocols accordingly. Mr. DeConciliis cautions facilities to avoid falling into the common trap of failing to follow their program's selection criteria. "There is a tendency to make exceptions to increase case volumes," he says.

Instead, he urges facility leaders to stick to the established selection process, set realistic case volume goals and constantly review outcomes data to determine when growth is possible. "You can begin to scale the program when complications are rare and procedures are successful," says Mr. DeConciliis. OSM