Key thoughts on outpatient joint replacement for obese patients

Written by Laura Dyrda | April 06, 2017 | Print  |

The SwiftPath RoundTables provide a forum where joint replacement experts work together to enable the safe development of outpatient joint replacement. RoundTable discussions are combined with cadaver-based bioskills labs to help focus attention on the most significant challenges faced by surgeons, providers, and facilities. A recent event took place in Long Beach, Calif., and was supported by Pacira Pharmaceuticals and Corentec: Launching the SwiftPath Triple Aim: A Bioskills Lab and RoundTable.

Surgeons discussed a variety of topics including patient selection, surgical approaches, modern pain management, preoperative nutrition and implant issues related to ASC joint replacement.

 

The following interview featured a focused discussion on the difficult issues surrounding obesity, patient selection and outpatient joint replacement, featuring:

 

• Dr. Peter Sharkey, The Rothman Institute in Philadelhpia
• Dr. Perry Secor, Long Beach, Calif.
• Dr. Craig McAllister, Proliance Surgeons, Inc. and Chief Medical Officer of the SwiftPath Program

 

Dr. McAllister: Gentlemen, let’s address the issue of obesity from the point of view of joint replacement surgery in general as well as from an outpatient joint replacement perspective. First of all, what are your thoughts on the issue and have they changed over the years?

 

Dr. Secor: I think the obesity issue has become more important over the last few years, especially now that we as surgeons are becoming accountable for bundles. Obese patients definitely are more likely to have complications that can be bundle busters. We really don’t have enough experience at this point to know the economics of the bundles. But let’s suppose the margin is $3,000. Then, let’s suppose there is a prosthetic joint infection, and it costs $100,000 to manage it. Well that's 33 joints where you would have made profit. The profit's gone on 33 joints, by having one infection.

 

CMM: There is no question that in the face of bundled payment methods and in the setting of ASC-based joint replacement surgeons simply can't afford to just keep operating on the patients without accounting for their unique risks and comorbidities. But The SwiftPath Program helps patients identify modifiable risks. Patients and surgeons can choose to move forward with surgery or schedule surgery after risks have been optimized. One of the most common questions I get as we launch programs across the United States is “What is your BMI cut off for outpatient joint replacement?” How would you answer that?

 

Dr. Sharkey: We used to have a moratorium on anybody with a BMI over 40, but we found that didn’t work.

 

Dr. Secor: I stopped doing that, too.

 

CMM: I agree completely. Simply looking at the BMI failed to prevent complications and prevented us from operating on many patients who truly needed the surgery and whose real risks were simply not accurately reflected by the BMI.

 

Dr. Sharkey: If you look at large numbers of cases, if you operate on enough people with a BMI over 40 most of them have a certain fat distribution. It might be over the knee, also over the hip. The specific distribution of the adipose matters. I saw a fellow the other day who came in for a total knee, he probably had legs that had no more adipose tissue on them than any of us. There's probably a quarter inch of fat over his knee. He eats really well. No diabetes, and he's got a BMI of 45. Now, would you rather operate on him, or let's say you had a 5'2" patient with a BMI of 35, who has eight inches of fat over the knee, is malnourished and has borderline diabetes? I guarantee you the patient with the BMI of 45 is going to have a lower infection rate.

 

Dr. Secor: But that kind of guidance comes from looking at a larger number of cases and looking at the data. You've got the data and you know how it works and then you modify those, understanding the risks from a factual standpoint. I have read studies where they measured the thickness of the tissue near the tibial tubercle and concluded that this was more predictive than simply looking at the BMI.

 

CMM: Indeed, that's what happens, if you run those patients through the SwiftPath Pathway Selection App, you'll see that the patients BMI is part of the equation. But to your point, if their BMI is 42, but they are otherwise fit, don't have significant medical problems, are highly motivated, have good support, and otherwise complete the program, they do very well with surgery. We've had plenty of those patients go home on the day of surgery. This is a great example of why all of the experts are calling for a fully integrated and comprehensive approach, one that combines patient empowerment, state-of-the art surgical techniques, and modern pain management. This type of approach is critical if we are going to provide the care without enduring the complications.

 

But what I have found ... You'll see in the SwiftPath platform there is no absolute anything. It's all a scoring system and everything's weighted. People have the same conversation about, "What about weight?" "What about medical problems?” “Charlson index?" "What about narcotic issues?"

 

Dr. Sharkey: Of all the things that SwiftPath does and talks about it, I feel that optimal perioperative management, identification of these kind of risks and preventing issues ahead of time are the most important.

 

Dr. Secor: But, in my humble opinion, I'm grateful for all this great work that SwfitPath has done. You're taking the key points and you're making it in to a checklist that we all follow. And the advantage of that is that we can all learn. If we're doing the same thing, and we're following the data closely, we can go see where outliers occur. We can find out where we can maybe do it better. Maybe do it in more cost effective ways. But we have the data to make the decisions. And if you don't standardize it, you can't do that.

 

CMM: I completely agree. Standardized, evidence-based clinical pathway guidelines are critically important. But experience and previous studies have shown that you can’t just write CPGs and throw them at the surgeon and expect surgeons to simply adopt them. You have to respect the surgeon as an expert and an artist, and give the surgeon a method that combines evidence-based CPGs with his or her art. This holds true with obesity as much as it does other optimizable risk factors like hypertension, weight, skin issues, and the seven patient factors that really lend themselves to, "I'm going to do your hip replacement, or your knee replacement, but before you do that I need you to fix that problem."

 

Our example of that is Joe. Joe came to me after three orthopedic surgeons refused him for a hip replacement. They refused him because of his weight, skin issues, COPD and diabetes. I know those surgeons. They are very good joint replacement specialists who are all part of bundled payment plans.

 

I refused Joe as well, and he became frustrated, complaining of severe pain— and his hip films were really painful looking. And I said, "Well, Joe, I've got a deal for you. You register for the SwiftPath Program, follow the steps, take control of your medical issues, and I will give you a surgery date in six months."

 

Six months later we did Joe's hip replacement on an outpatient basis. We didn't have a single complication. The point is, when he changed those factors, and then he took the survey and qualified as an outpatient surgery.

 

More articles on orthopedics:
Prevea Health welcomes Dr. Joseph McCormick
Erlanger Health System reduces LOS with Orthopaedic Institute opening
Olympia Orthopaedics Associates adds Dr. Milan Moore

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