New Research Shows Rapid Shift of Total Joint Surgeries to Outpatient
Even though the uptick in the move coincides with the pandemic, study authors say the change is permanent
BY ALEX TAIRA | FEBRUARY 2023
Thanks to advancements in medical techniques and devices, surgeons are performing an increasing number of total joint surgeries in the outpatient setting. According to a preprint article in The Journal of Arthroplasty, the proportion of elective total joint arthroplasty (TJA) patients who experienced same-day discharge in 2021 was more than 30 percent, up from less than 1 percent of patients undergoing TJA in 2017.
TJA migration to outpatient sites of service began before the COVID-19 pandemic onset in 2020. In January 2018, the Centers for Medicare & Medicaid Services (CMS) moved total knee arthroplasty (TKA) off the inpatient-only (IPO) list, making the procedure reimbursable in hospital outpatient departments (HOPD). In January 2020, CMS added the procedure to the ASC Covered Procedures List (ASC-CPL). The agency also moved total hip arthroplasty (THA) from the IPO list in 2020 and added it to the ASC-CPL starting in 2021. A certain proportion of commercial TKAs and THAs were already being performed in the outpatient setting prior to these changes in CMS payment policy. The Medicare changes, however, signaled a federal regulatory belief that the procedures could be performed safely on Medicare beneficiaries, a patient cohort that is by nature older and less healthy than the general population. Notably, some of these regulatory changes occurred during the COVID-19 pandemic; TJAs are considered elective surgeries and elective surgeries were halted for at least some time in all states during the early onset of the pandemic.
Researchers from the Department of Orthopaedic Surgery at the Keck School of Medicine of the University of Southern California looked at all patients who underwent primary elective THA or TKA from 2017 to 2021. They separated patients into three time periods: 2017 to 2019, 2020, and 2021, with the latter two periods occurring during the COVID-19 pandemic. The outcomes of interest were length of stay (LOS), discharge status and patient characteristics. The sample included 1.17 million patients undergoing elective TJA but none of them underwent TJA surgery in an ASC.
||SOURCE: Department of Orthopaedic Surgery, Keck School of Medicine, USC
From 2017 to 2019 (the pre-pandemic period), roughly 270,000 cases of elective TJA were performed per year. This number dropped 35 percent to about 175,000 cases in 2020 and 30 percent to 188,000 cases in 2021. The drop in volume is not surprising given the previously mentioned halt in elective surgery and general patient avoidance of hospitals in those years. LOS was already decreasing in the years prior to the pandemic—average LOS of 2.2 days in 2017 had decreased to 1.7 days in 2019—but the trend accelerated considerably because of the pandemic. After October 2020, no single month saw an average LOS greater than 1.2 days, and the average LOS in December 2021 reached a new low of 0.94 days.
The proportion of patients experiencing same-day discharge mirror the declines in LOS. Whereas fewer than 1 percent of patients were discharged same-day in 2017, almost one third (30.5 percent) of elective TJA patients were discharged same-day in 2021. The number of patients that were discharged into a skilled nursing facility (SNF) also declined during the pandemic; in 2017 13.5 percent of patients were discharged to an SNF, a proportion that decreased to just 4.5 percent in 2021.
The authors assert that the pandemic accelerated trends in elective TJA surgery that were already occurring in the years prior. These trends include reduction in LOS and discharge to SNFs and increases in proportion of patients experiencing same-day discharge. The authors state that this is the largest sampling of inpatient hospital TJA procedures in 2021 and conclude that the trends observed in this study are likely permanent changes to TJA practice patterns rather than temporary pandemic-related aberrations.