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patients overnight," he says. "I think there's a psychic benefit to getting
back in your own bed rather than the stigma of being in a hospital and
getting woken up at 2 a.m. and 4 a.m. for vital signs."
In 2016, outpatient settings represented 15% of all primary hip and
knee replacements, according to healthcare analytics firm Sg2. By
2026, outpatient is expected to outpace inpatient's share of volume,
51% to 49%. Last year CMS announced it would consider striking pri-
mary total knee replacement procedure from its "inpatient-only" list.
"Outpatient joint replacements are a significant cost savings to the
system," says Harbinder S. Chadha, MD, an orthopedic surgeon with
Otay Lakes Surgery Center in San Diego, Calif. "Comparing the hospi-
tal to the surgery center, it's about one-third of the cost, and that's
why [insurers] are allowing it."
Dr. Chadha, who specializes in total hips, says new technology and
instrumentation have enabled surgeons like him to perform total joint
surgeries outside the hospital with repeatable, predictable outcomes.
Besides changes in how the surgery is being performed, outpatient
surgical facilities have also had to transform how they approach post-
op pain control — opioid-sparing multimodal regimens are increasing-
ly popular — and patient selection. Dr. Martin says surgeons and their
staff now do "a lot more work" in terms of pre- and post-op planning.
But not everyone is a suitable candidate.
"We as physicians need to stick to strict criteria, especially as our
comfort level eases," says Dr. Martin, "because you don't want any
complications when the patient is home."
An example: working with obese patients to optimize their weight
before surgery, especially for total knees and total hips. Dr. Martin
recommends drawing a line at a BMI of 40, and working with non-
optimal patients to lose weight as a means of reducing the risk of sur-
gical complications.
