Surgical Shift: Outpatient Surgeries Improve Patient Experience, Outcomes
Opting for Outpatient
The advent of new technologies and minimally invasive techniques has made it possible for more surgeries to be performed on an outpatient basis. That means fewer procedures require a prolonged stay afterward – whether at the hospital or ambulatory surgical center. Instead, an increased number of patients are recovering at home after the effects of anesthesia wear off.
Data gathered by Cedar Gate Technologies from more than 12 million commercial insurance members show that inpatient surgeries decreased 7.33% from 2019 to 2021, while utilization rates for non-inpatient facilities increased. Hospital outpatient surgery volume increased 3.1%, and ambulatory surgical center utilization rates rose by 10.26%.
Experts say the greatest number of procedures shifting from inpatient to outpatient right now are concentrated in orthopedics, cardiology, and radiology service lines, including procedures like percutaneous coronary interventions (PCI), total hiparthroplasty (THA), total knee arthroplasty (TKA), spinal fusion, spinal decompression, and laparoscopic cholecystectomy (gallbladder removal). These procedures are more complex than those traditionally performed in ambulatory settings.
Additionally, patients requiring treatments like dialysis or infusions traditionally performed at outpatient centers are increasingly offered opportunities to receive these treatments in the privacy and comfort of their own homes.
“In this era of care, we are seeing more procedures and treatments moving from inpatient to outpatient and from outpatient to home,” says Philip M. Oravetz, MD, MPH, Chief Population Health Officer at Ochsner Health. “Moving care, when appropriate, ‘checks all the boxes’ in terms of goals for value-based care. This transition often provides equal or better care quality and outcomes and greatly improves patients’ experience, and the side effect is lower cost. This transition is also a great way to engage specialists and community providers. They can help fuel the movement by assisting in the care redesign process.”
How Do Outpatient Surgeries, or Home Treatments, Meet the Definitions of Value-Based Care?
While outpatient options have been increasing for many years, the COVID-19 pandemic played a definite role in patient choice. Many avoided hospitals altogether in 2020 and 2021, opting to cancel or delay elective procedures due to fear of infection. Once these patients were ready to resume their treatment plan, they seemed to seek options that would keep them out of the hospital for an extended basis.
For many types of non-emergency surgeries, outpatient procedures offer patients the convenience and comfort of recovering at home. Because the patient is not spending time recovering in the hospital, the risk for a hospital-acquired infection is much, much lower.
Patients undergoing dialysis and certain infusions at home also report a much-improved experience, as the transition allows for the convenience of scheduling treatments that fit their routine and a greater degree of control and independence when it comes to managing their health. An environment that helps them feel comfortable and relaxed promotes healing, and they don’t have to worry about the stress of traveling to a center, giving them more time back to do the things they love. Certain types of home dialysis allow patients to sleep during the procedure or do more frequent, shorter treatments, both of which can improve patient outcomes and reduce dietary restrictions. Patient education, especially when it comes to proper safety and sanitation protocols is, of course, essential.
“By offering outpatient options for many of the surgeries our highly skilled providers perform, we are creating better patient outcomes and experiences at a lower cost, which also translates to shared savings for those surgical providers,” says Dr. Oravetz. “All of our surgeons use the latest tools, technologies and evidence-based protocols to determine if patients are eligible for outpatient procedures and deliver the highest quality care during those procedures. Patients can then recover in the comfort of home, surrounded by a familiar environment and the people they love, which most people prefer.”
Of course, some procedures cannot be performed on an outpatient basis, and if a patient has complex health issues that might put them at high risk, an inpatient surgery and stay might be the better option even an outpatient option is available. The same holds true with determining patient eligibility for at-home dialysis and infusions.
If a patient is eligible for an outpatient procedure, there is also always a small chance that a complication or emergency might make a transfer and an overnight stay necessary. But complications are uncommon, and a significant number of people each year undergo outpatient procedures.
At physician-owned ambulatory surgical centers, the surgeons and physicians have a great deal of control over how the center is used, who they hire, and what technologies and products they use. Because surgical patients are seen and treated in a controlled environment, these outpatient centers can use business intelligence and metrics to effectively measure the outcomes of surgical procedures and identify areas for improvement. Data-driven refinements to surgical techniques can reduce complications and improve patient outcomes. These are defining elements of value-based care.
Data collected by these outpatient centers also includes information about patient recovery times, patient education, pain management and what steps are taken after surgery (post-op care, rehabilitation and therapy, etc.). This patient health and satisfaction data helps inform future protocols, improve patient outcomes and reduce the risk of complications in defined populations.
There’s already been an aggressive move to outpatient for joint replacements, and other procedures are sure to follow.
“Same-day discharge hip and knee replacement had been going on for several years, but was not very widespread,” says George Chimento, MD, System Chair, Orthopedic Surgery at Ochsner Health. “When the Centers for Medicare & Medicaid Services took total knee replacement off the inpatient-only list, same-day joint replacement gained more traction. This was accelerated by the pandemic, as across the nation, hospital capacity was at a maximum, and they were filled with COVID patients.”
In order to be able to have hip or knee replacement surgery, patients needed to go home the same day.
“A study from the University of Utah showed that prior to the pandemic, 15% of their patients went home the same day. By the end of the pandemic, they were sending more than80% of patients home the same day,” Dr. Chimento says. “The key point here is that there was no decrease in quality, such as complications and readmissions.”
He says regional anesthesia, multimodal pain control and widespread adoption of tranexamic acid, which decreases blood loss, were the main factors that made the transition relatively seamless.
“Surgeons had already developed tissue-sparing, less invasive techniques, and these other factors complemented those in such away that patients can be safely discharged on the same day,” Dr. Chimento says. “There are also obvious financial incentives for surgeons and hospitals to decrease the length of stay, and this shows that surgeons from both academic and private practice, as well physicians from different specialties, can work together for a common goal in safely redesigning care in a way that brings more value to patients as well as the healthcare system.”
Physicians Are This Movement’s Natural Leaders
In all cases, providers need to meet at the table to understand which patients are the best candidates for either outpatient or home treatments.
“As chronic kidney disease prevalence increases, it becomes more important to find new and innovative ways to keep patients healthy and home,” says Sean Roberts, MD, a nephrologist at Ochsner. “Specifically, providing more dialysis services in the patient's home is a major step in improving the quality of life for ESRD patients and helps keep them with their families in familiar surroundings with the least impact on their quality of life. Leveraging new technology along with our EMR is how we will achieve this goal to provide quality care in the comfort of the patient's home.”
“As providers, we have a responsibility to our patients to get involved in the care redesign process and help to move care when it’s appropriate,” adds Dr. Oravetz.
Article acknowledgements:
Thank you to OHN physicians who contributed their time and expertise to this article.
