Present and Future Trends in Total Joint Replacement (TJR) in ASCs

In this episode of the Advancing Surgical Care Podcast, ASCA Chief Executive Officer Bill Prentice talks with Michael Patterson, FACHE, president and chief executive officer of Mississippi Valley Health in Davenport, Iowa, and immediate past president of the ASCA Board. During their conversation, Prentice and Patterson discuss total joint replacement (TJR) procedures in ASCs today, projections for the future, the growing body of quality data for TJR procedures in ASCs, the acquisition and deployment of robotic devices in ASCs and the future potential for more inpatient-only procedures to migrate to the ASC setting.

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Narrator:   0:06
Welcome to the Advancing Surgical Care Podcast brought to you by ASCA, the Ambulatory Surgery Center Association. ASCA represents the interests of outpatient surgery centers of every specialty and provides advocacy and resources to assist them in delivering safe, high-quality, cost-effective patient care. As with all of ASCA’s communications, please check to make sure you are listening to or viewing our most up-to-date podcasts and announcements.

Bill Prentice:   0:37
Hello, and welcome to the Advancing Surgical Care Podcast brought to you by the Ambulatory Surgery Center Association, or ASCA. My name is Bill Prentice, I’m ASCA’s CEO and the host of this episode. We’re recording today at the ASCA conference and expo in Dallas, Texas. My guest today is Michael Patterson, the outgoing ASCA president and CEO of Mississippi Valley Health in Davenport, Iowa. For the past two years, Michael has helped ASCA by leading us through the challenges of the COVID-19 pandemic, so we’re very pleased to have him with us this week as we return to in-person meetings. Before joining Mississippi Valley Health, Michael held a variety of positions in healthcare ranging from a registered nurse in a level one trauma center to the chief administrative officer of a 350-bed community hospital, and chief nurse executive of a three-hospital healthcare system. Michael also served for more than 23 years in both the active and reserve components of the US Navy and was deployed multiple times to provide trauma care around the world before retiring with full honors in 2012. And we thank him for that service as well. And with that introduction, Michael, welcome to the podcast.

Michael Patterson:   1:44
Thanks, Bill. Appreciate the opportunity to visit with you for a bit.

Bill Prentice:   1:47
Michael, as I mentioned a moment ago, we had you on the podcast back in 2019 to share some experiences and insights that you had at Mississippi Valley Health as one of the early pioneers of performing total joint replacement surgeries in an ASC setting. Since then, we’ve seen continuous growth in the number of these procedures and forecasts that say these trends are likely to accelerate even faster in the years ahead. We’ve also seen improvements in anesthesia and postoperative pain management, and some really fascinating advances in the use of robotics. So, there’s obviously a lot to talk about since our last podcast. Let’s start by looking at some of the trend lines I just mentioned. What can you tell us about future demand for hip and knee replacement procedures, as well as the prospect for additional shoulder surgeries moving outpatient?

Michael Patterson:   2:35
Bill, the trends are continuing to arise as predicted. In 2022, we saw a 37 percent increase and the prediction of by 2026, we’re going to see a 51 percent increase in outpatient total joint replacement. I think that this is going to continue well beyond the next several years and Medicare is predicted to spend a significant amount of money, almost 50 billion, on total joint replacement by 2030. We can talk about the volume that’s predicted of somewhere close to between three and three and a half million total joint procedures being done. And as everyone’s probably aware, as of 2020 knees are now allowed in the surgery center, since 2021 hips are allowed in the surgery center. And we’re excited about the opportunity for shoulders—we see a lot of those still going to the hospital and we think there’s an absolute place for that in the surgery center. We do them for commercial patients and I think it’s the next evolution, and I have a lot of orthopedic surgeons who are really looking forward to seeing the ability to do those procedures in an ambulatory surgery setting.

Bill Prentice:   3:46
Well, an added benefit of having that volume of procedures that you just mentioned moving to the ASC is that we’re now getting, and will continue to get, a considerable amount of quality data and patient satisfaction scores on which to draw some very reliable conclusions about the safety and outcomes associated with outpatient total joint procedures. So first, what can you tell us about total joint replacement quality data that you’re seeing and how ASCs compare to other sites of care? And second, how are the advances in postoperative pain management affecting outcomes and patient satisfaction scores?

Michael Patterson:   4:22
So, Mississippi Valley Surgery Center, located in Davenport, Iowa—we’re the only advanced certified, AAAHC-accredited ortho and spine facility in the state. So, we have a deep dive into our quality data and we take a look at that against national data. So, for instance, let’s just talk about infections. The national average is about 2.5 percent of patients undergoing total joint replacement will come down with some sort of an infection. At our particular facility, Mississippi Valley Surgery Center, our rate is 0.2 percent.

Bill Prentice:   4:52
Wow.

Michael Patterson:   4:53
And we’re really proud of that. The other piece of that is net promoter score. It’s an indicator of whether or not someone, a patient or a customer, will recommend or refer their friends and family and others to your facility. And currently, our net promoter score for just our total joint patient population is at 99 out of 100.

Bill Prentice:   5:16
That’s impressive.

Michael Patterson:   5:17
And our physicians love working in the surgery center, our patients love getting care in the surgery center. We have a mixed model now where some patients go home same day, and we also have the ability to keep some patients overnight. And just depending on that particular patient and what they decide in conjunction with the surgeon makes the decision capability of are they going to stay or are they going to go? And we found a lot of success working through that. I think the other significant piece of quality in an ambulatory surgery center is a nurse navigator. We have two full time ortho nurse navigators who walk all of our total joint and our spine patients through every step of their procedure preoperatively, they’re there to meet them on the day of surgery, and then they talk to them postoperatively to assess and to figure out if there are any issues that they’re having, and how do we rectify those before they happen? Or if there’s something that happens afterwards, how do we correct those? And that has worked really, really well. We’re very proud of both of our ortho nurse navigators.

Bill Prentice:   6:18
That seems to be a really valuable addition if you’re going to be doing those types of procedures at the volumes you’re doing them. Well, that’s amazing. And I know we’re going to talk in a minute or two about robotics. But before we do that, I’m going to ask that we take a short pause to hear a quick word from our podcast sponsor. We’ll be right back.

Narrator:   6:36
This episode of the Advancing Surgical Care Podcast is being brought to you by National Medical Billing Services, an ASCA affiliate and leading ASC revenue cycle company that helps ASCs properly capture their revenue and maximize their cash flow in a highly compliant fashion. To learn more about National Medical Billing Services’ wide range of revenue cycle services and analytics, visit nationalascbilling.com.

Bill Prentice:   7:08
Michael, as I mentioned before the break, I know that Mississippi Valley Health has begun to employ robotic devices in total joint procedures. What can you tell us about that experience in terms of both the learning curve for your surgical teams as well as how this equipment can further improve the quality of the surgeries that are being performed in your facility?

Michael Patterson:   7:26
Mississippi Valley Surgery Center has a great story when it comes to the implementation of robotics. We started doing total joint replacements in 2007 and received our advanced accreditation in 2019. And then we recruited a new surgeon that as part of that recruitment said, “Look, I feel the future of total joint replacement is with the use of robotics.” He was well vetted; he has vetted all of the commercially available systems out there, and there are several of them. When I really tried to understand what this means not only for patients, the surgery center, the physicians, the staff, turnover time, cost—all of those factors came into play. But typically, you end up with less tissue damage, you preserve more healthy bone by using that. The patients get a CT scan and it creates a customized approach to how the surgeon is going to do the surgery, how the robot makes the cut, and then the specific implant that’s implanted. And along with that, there’s a lot of other support that goes with that robot. We have somebody who is there just solely to operate the robot and make sure that everything is good to go with the robot, as well as the traditional reps that are in the room. We did a nice job of training and orientating our staff prior to executing, implementing the robot and doing first cases. We had a surgeon that had almost 500 robotic cases under his belt when he came, which is a huge factor. And I think the other interesting thing to note is what I call our senior orthopedic surgeon—who’s well into his late 60s, who has done well over 10,000 joint replacements—has adopted this and solely now uses robotic technology because his partner came and, with their other partner, there’s three of them that do that. They made a commitment that if we’re going to make this leap into robotics, then we all need to use this, we all need to learn it and understand it and get behind it. And they all have, and it has really made for a successful robotic program at our facility.

Bill Prentice:   9:26
That’s very impressive. And it’s very interesting to hear that you can teach old surgeons new tricks.

Michael Patterson:   9:30
That you can.

Bill Prentice:   9:31
Very cool. Michael, as we sit here at ASCA 2022 on April 28, 2022, I think we’re all hopeful that the worst of the COVID-19 pandemic is behind us and that we’ll soon see a reduction in the inflationary pressures that have caused so much harm in the economy in recent months. You and I have talked a lot about hiring challenges as well as the constant upward price pressure and lack of availability of essential medical supplies. What can you tell us about how Mississippi Valley Health is managing these difficult challenges and whether or not you’re seeing any improvement on the horizon, either in terms of staffing or the cost of the essential supplies and equipment you need to run your facility?

Michael Patterson:   10:11
Yes. The change post-pandemic in regard to staffing and supplies has been pretty significant—we monitor that closely. We saw some of our most seasoned nurses decide to retire and it’s great for them. And we saw some changes in the way other folks decided they wanted to continue to progress their career. You take that in competition with a national demand for nurses and surgical techs, and the proliferation of travel nursing and opportunities that would pay somebody typically four or five times what they normally would make, that created some challenges as well as some opportunities for us. We really focused on culture, which I think all of us need to pay close attention to, and ensuring that we were being competitive in our market and listening to our employees. Some of the things that we’ve done is we’ve shortened our OR days, which sometimes the surgeons don’t like. But in order to ensure that everyone has this work-life balance and was able to recognize these changes, we shortened our OR days. And some of that is purely due to lack of childcare for some of our staff, others just made that conscious decision to spend more time at home, and the pandemic allowed us to do some of that, and a lot of us really like that. So that’s one component of it, culture, recruitment, being competitive on your benefits. And then the next piece of what’s going on there, obviously, is the access to supplies and, more importantly, pharmaceuticals. National shortages, a significant three to four times price increases on certain drugs that are, quite frankly, required in order to do surgery really put it on our materials management team and some of those folks to do a lot of searching for: 1) Where do they get access at? And 2) How do we ensure best pricing? And we’re still battling that battle. And I don’t know that either of those are going to change significantly moving forward. It’s just this new world that we’re going to live in and really have to understand case costing on the supply side, and then ensuring that we are recruiting and retaining the right people to do the work that is so important in our surgery centers.

Bill Prentice:   12:33
Yes, a lot of work involved in that. I’m sure it makes for some long days for you, but you seem to be weathering them well. This has been a wonderful conversation and I learn so much when I talk with you, Michael, and I appreciate you being on the ASC podcast again with me.

Michael Patterson:   12:49
Thanks. I appreciate the opportunity to talk to folks and explain the great things that we’re doing and some of the things we’re going to continue to do.

Bill Prentice:   12:57
Great. Before concluding, I’d also like to once again thank our podcast sponsor, National Medical, an ASCA affiliate and leading ASC revenue cycle company. To learn more, visit nationalascbilling.com.