Acute Hospitalizations Following Outpatient Orthopedic Surgery (HFO)

For persons 65 years of age and older, the risk-adjusted ratio of observed-to-expected unplanned acute hospitalizations (inpatient and observation stays) for any diagnosis that occurred within 15 days following select outpatient orthopedic surgeries.

Why It Matters

Outpatient, or ambulatory, surgeries are planned surgeries where the patient is not expected to be admitted to an inpatient setting. Though most facilities primarily offer same-day surgeries, some provide extended stay services to patients who need additional recovery time or monitoring 1. Surgical procedures are increasingly moving from the inpatient to the outpatient setting, with over 50 million procedures (translating to about 70 percent of all surgeries) now performed in ambulatory settings each year 2 3.

In one study, researchers found the most common reason for emergency department (ED) visits within 30 days of outpatient orthopedic surgery was infection 12. Following outpatient orthopedic surgery, wound management, improved preprocedural risk assessments and improved patient counseling of risk factors can minimize ED visits and complications 12.

Payment arrangements and financial incentives have been a major driver in the transition to outpatient surgery. As of 2020 there were 5,930 ambulatory surgery centers (ASC) in the US that have been certified by CMS to receive full reimbursement for services provided to Medicare beneficiaries. In 2020, Medicare spent $4.9 billion on treatment and procedures at ASCs 4. There has been a growth in the number of ASC facilities and the number of procedures performed in these settings. Between 2015 and 2019 the total number of ASCs increased each year by an average of 2.1 percent, the majority of which were for profit, physician-owned facilities. During the same period there was an average increase of 6.7 percent in payments for ASC services for Medicare fee for service (FFS) members 4.

Studies have found that cost savings for payers for outpatient procedures compared to similar inpatient procedures are significant, ranging from around 15% to 60% depending on procedure type 5 6 7. For example, a study found that outpatient unicompartmental knee arthroplasties were, on average, about $20,000 less per patient than those performed in an inpatient setting 6.

Advances in surgical technologies, perioperative care and payment structures have increased the number and variety of surgical procedures performed in outpatient settings.

The same-day nature of most ambulatory procedures limits the opportunity for direct oversight of patients in the hours and days after surgery, which makes patient surveillance and management of potential complications difficult 8. Care coordination is therefore critical for capturing problems early and ensuring positive patient outcomes. This is true for all outpatient surgery settings but particularly for independent, freestanding ASCs that are not integrated with a larger health system.

Certain patient characteristics and risk factors can increase the chances of complications following outpatient surgical procedures. A study of over 400,000 elective outpatient procedures showed that the risk of complications was significantly higher among patients with frailty compared to those without frailty 9. Another study of 170,000 patients who underwent an outpatient total joint arthroplasty showed an overall complication rate of 8 percent, with a significantly increased risk of complications among patients with malnutrition, history of cardiac problems or smoking, diabetes mellitus and those over age 70 10. While certain risk factors are not usually independently associated with outpatient surgery complications, studies documented a higher risk of complications when multiple risk factors are present.

Historical Results – National Averages

Performance results for this measure are currently unavailable.

References

  1. Steiner, Claudia A., Zeynal Karaca, Brian J. Moore, Melina C. Imshaug, and Gary Pickens. 2020. “Statistical Brief #223: Surgeries in Hospital-Based Ambulatory Surgery and Hospital Inpatient Settings, 2014.” Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. http://www.ncbi.nlm.nih.gov/books/NBK442035/
  2. Gabriel, Rodney A., Ruth S. Waterman, Brittany N. Burton, Sophia Scandurro, and Richard D. Urman. 2021. “Patient Health Status and Case Complexity of Outpatient Surgeries at Various Facility Types in the United States: An Analysis Using the National Anesthesia Clinical Outcomes Registry.” Journal of Clinical Anesthesia 68 (February): 110109. https://doi.org/10.1016/j.jclinane.2020.110109
  3. Hollenbeck, B. K., R. L Dunn, A. M. Suskind, Y Zhang, J. M. Hollingsworth, and J.D. Birkmeyer. 2014. “Ambulatory Surgery Centers and Outpatient Procedure Use Among Medicare Beneficiaries.” Medical Care 52 (10): 926–31. https://doi.org/10.1097/MLR.0000000000000213
  4. MEDPAC. 2021. “Chapter 5: Ambulatory Surgical Center Services.” In Report to the Congress: Medicare Payment Policy, 133–60. Washington, DC: MEDPAC. https://www.medpac.gov/wp-content/uploads/2021/10/mar21_medpac_report_ch5_sec.pdf
  5. Crawford, Dennis C., Chuan Silvia Li, Sheila Sprague, and Mohit Bhandari. 2015. “Clinical and Cost Implications of Inpatient Versus Outpatient Orthopedic Surgeries: A Systematic Review of the Published Literature.” Orthopedic Reviews 7 (4): 6177. https://doi.org/10.4081/or.2015.6177
  6. Richter, Dustin L., and David R. Diduch. 2017. “Cost Comparison of Outpatient Versus Inpatient Unicompartmental Knee Arthroplasty.” Orthopaedic Journal of Sports Medicine 5 (3): 2325967117694352. https://doi.org/10.1177/2325967117694352
  7. Tanaka, Miho J. 2019. “Ambulatory Surgery Centers Versus Hospital-Based Outpatient Departments: What’s the Difference?” September 1, 2019. https://www.aaos.org/aaosnow/2019/sep/managing/managing02/
  8. Theissen, A., K. Slim, A. Deleuze, and M. Beaussier. 2019. “Risk Management in Outpatient Surgery.” Journal of Visceral Surgery, Forensic aspects of surgical practice, 156 (September): S41–49. https://doi.org/10.1016/j.jviscsurg.2019.04.005
  9. Rothenberg, Kara A., Jordan R. Stern, Elizabeth L. George, Amber W. Trickey, Arden M. Morris, Daniel E. Hall, Jason M. Johanning, Mary T. Hawn, and Shipra Arya. 2019. “Association of Frailty and Postoperative Complications With Unplanned Readmissions After Elective Outpatient Surgery.” JAMA Network Open 2 (5): e194330. https://doi.org/10.1001/jamanetworkopen.2019.4330
  10. Courtney, P. Maxwell, Anthony J. Boniello, and Richard A. Berger. 2017. “Complications Following Outpatient Total Joint Arthroplasty: An Analysis of a National Database.” The Journal of Arthroplasty 32 (5): 1426–30. https://doi.org/10.1016/j.arth.2016.11.055
  11. Bernatz, J. T., Tueting, J. L., Hetzel, S., & Anderson, P. A. 2016. “What Are the 30-day Readmission Rates Across Orthopaedic Subspecialties?” Clinical Orthopaedics and Related Research, 474(3), 838–847. https://doi.org/10.1007/s11999-015-4602-5
  12. Gonzalez, M., Ganta, A., & Sapienza, A. 2020. “Postoperative Inpatient Conversions Following Ambulatory Orthopedic Surgery.” Bulletin of the Hospital for Joint Disease, 78(4), 255–259.

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