Outpatient Orthopaedic Surgery: Recent Trends in the Medicare Population

The performance of orthopaedic procedures in ambulatory surgery centers (ASCs) continues to increase in the US. This practice is accelerating for multiple reasons: patients want to sleep in their own beds, hospitals can present a risky environment for nosocomial infection, inpatient surgical care is more costly, and some surgical teams find greater efficiency functioning in high-volume outpatient surgery centers—to name a few explanations for the shift we’re seeing. Over the last few years it has become clear that, in properly selected patients, certain arthroplasty procedures can be safely performed in the outpatient setting  with high patient satisfaction. Resources can be saved and directed to care that must be delivered in the hospital environment. 

New data on outpatient orthopaedic procedures in the Medicare population are presented in the latest issue of JBJS by Lopez et al., who examined trends in ASC procedure volume, utilization, and reimbursements between 2012 and 2017. They note that: 

• A total of 1,914,905 orthopaedic procedures were performed at ASCs in the Medicare system during the study period, with an 8.8% increase in annual procedure volume and a 10.5% increase in average reimbursements per case.  
• Increasing procedure volume was driven significantly by increases in hand procedure volume. 
• All states but Vermont were found to have ASCs, with most being located in the South (39.8%), followed by the West (26.5%), Midwest (20.1%), and Northeast (13.6%). ASC procedure utilization was strongly associated with metropolitan areas compared with rural areas.  
• Orthopaedic procedure utilization, including for sports, hand, and spine procedures, was significantly higher in wealthier counties as well as in counties in the South. 

While an analysis of safety was outside the scope of this study, data have been reported elsewhere confirming that safety can be achieved in the outpatient setting. Our community must also address value, paying attention to implant and supply costs to trim waste and conserve resources wherever possible. It is my belief that somewhere around 80% to 85% of all orthopaedic procedures have the potential to be performed in outpatient environments if we expand the indications slowly and carefully along with the practices of regional anesthesia, home nursing care, and after-hours consultative resources to place patients and families at ease with these expanding programs over time.   

Marc Swiontkowski, MD
JBJS Editor-in-Chief