Successfully Implementing an Outpatient Total Hip Arthroplasty Program

    Why would an orthopaedic surgeon want to consider performing total hip arthroplasty (THA) on an outpatient basis? Ryan M. Nunley, MD, from Washington University School of Medicine in St. Louis, Missouri, can think of a few reasons:

    Space limitations. Hospitals are often at maximum capacity, which limits the number of beds available for patients undergoing elective surgery. Dr. Nunley’s institution, for example, has only 70 beds allotted for orthopaedic inpatients.

    Patient demand. Many of today’s joint replacement patients are younger and/or living an active lifestyle, and they’re asking if they can be discharged home the same day as surgery. Patient satisfaction may be improved, Dr. Nunley said, when joint replacement patients can recover at home, in their own beds.

    Value-based care. Orthopaedic surgeons can add value to the episode of care by helping to decrease healthcare spending while maintaining quality care and good patient outcomes.

    Market pressure. Not surprisingly, commercial insurers have followed the lead of the Centers for Medicare and Medicaid Services (CMS) and have implemented bundled payment models for the joint replacement patients they cover. In addition, CMS has already removed total knee arthroplasty from the inpatient-only list and is considering doing the same for THA.

    Dr. Nunley and his partners began taking steps toward outpatient joint replacement  more than a decade ago with the development of rapid recovery protocols. [1] The process was implemented slowly, over the course of years, to ensure that the changes were not adversely affecting outcomes or causing an increase in complications and readmissions. The 10-step “patient journey” they developed is designed to:

    • Identify appropriate candidates for outpatient procedures
    • Optimize patient health preoperatively
    • Educate patients and their “joint coach” in preoperative classes
    • Provide consistent protocols and order sets

    A comparison of data from UHC primary member hospitals shows that this approach is working: Although Barnes-Jewish Hospital, where Dr. Nunley practices, is one of the highest-volume member hospitals, it also has one of the lowest lengths of stay and one of the lowest 30-day readmission rates. Implementation of the Bundled Payments for Care Improvement (BPCI) initiative in July 2015 added a financial dimension to the data, Dr. Nunley said, and resulted in efforts to reduce readmissions and utilization of skilled nursing facilities.

    Dr. Nunley noted that approximately 15% of his patients are appropriate candidates for outpatient joint replacement, while 30% are not good candidates and should proceed on the traditional inpatient pathway. The other 55% of his patients fall into a gray area: They might or they might not be appropriate candidates for outpatient surgery. The key, Dr. Nunley said, is to determine if patient optimization and education could move at least some of them could to a “yes” for same-day discharge or a short-stay procedure.

    Click the image above to watch Dr. Nunley’s presentation on outpatient joint replacement surgery from ICJR’s 1-day meeting, Essential Hip Topics: Cradle to Grave.


    Dr. Nunley has no disclosures relevant to this presentation.


    1. Stambough JB, Nunley RM, Curry MC, Steger-May K, Clohisy JC. Rapid recovery protocols for primary total hip arthroplasty can safely reduce length of stay without increasing readmissions. J Arthroplasty. 2015 Apr;30(4):521-6. doi: 10.1016/j.arth.2015.01.023. Epub 2015 Jan 23.