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Outpatient Total Joint Arthroplasty: Patient Selection and Preoperative Planning for ASCs

ASC surgeon performing Total Joint Arthroplasty


  • More than half of all joint surgeries are estimated to be outpatient by 2026.
  • Patient selection is the most significant factor driving the success of TJA procedures in ASCs. Surgeons can use the OARA score and other patient evaluation parameters to optimize the process.  
  • Intelligent AI-based preoperative planning can help ASCs maintain patient safety and gain cost-efficiencies. 


Ambulatory Surgical Centers (ASCs) are rapidly becoming a preferred destination for primary total knee arthroplasties (TKAs) and primary total hip arthroplasties (THAs). More than half of all total joint arthroplasties are estimated to be outpatient procedures by 2026. In an ASC, payers can experience 35% to 50% lower costs than in a hospital setting.

The trend of total joint replacement as an outpatient procedure is not entirely new. Private payers have embraced TKAs as a hospital outpatient procedure or in an ASC since 2010. But after the Centers for Medicare and Medicaid Services (CMS) added TKAs and THAs to their ASC-covered list in 2020, the number of total joint surgeries in ASCs is expected to boom.  

Want to learn more about how our products help ASCs? Check out how effective pre-operative planning software can specifically assist total hip arthroplasties in ambulatory surgical centers. 

Why Ambulatory Surgical Centers (ASCs)? 

ASCs are an alternative to hospital-based surgery for lower-risk procedures and are gaining popularity across the United States. Benefits to patients include lower costs and the experience of value-based care without having to stay overnight. Many ASCs are also smaller facilities.

This offers patients and their caregivers a more intimate and potentially less overwhelming environment than a large hospital. While ASCs can never entirely replace a hospital, the list of procedures approved for ASCs is growing. 

The Pressing Need for Efficiency in an ASC

ASCs have to adhere to the same quality of care and standards as a hospital – but are reimbursed at a lower rate than hospitals. ASCs need to employ and retain qualified surgeons, OR staff, nurses, assistants, and the myriad of skilled healthcare workers that make up the surgical ecosystem. In a highly regulated industry like healthcare, there are many protocols, documentation guidelines, record-keeping, and more. Many healthcare workers face burnout

ASCs can continue to offer their patients value-based care and meet their expectations by enhancing the patient selection process and leveraging advancements in preoperative planning technology. 


Patient Selection is Important for TJAs in ASCs 

Selecting the right patients for a total joint replacement procedure in an ASC is one of the most significant factors affecting the success of the procedure. It also impacts overall patient satisfaction and the cost-effectiveness of the entire facility. 

Patients with no or limited comorbidities are ideal choices for ASCs since they will benefit most from at-home recovery. 

Currently, orthopedic surgeons around the country are in the process of developing, evaluating, and refining their preoperative pathways to select the right patient for a same-day ASC procedure. Eventually, having a standardized way to assess patients for outpatient and ASC settings is ideal for maintaining quality across the country and gaining process efficiencies. 


OARA Score and Patient Selection Pathways for Outpatient TJA 

Meneghini et al. developed the OARA score –Outpatient Arthroplasty Risk Assessment – to help orthopedic surgeons and their teams evaluate patients for outpatient joint surgery. Traditionally, surgical teams used the ASA score (American Society of Anesthesiologists) to study a patient’s health before surgery. The OARA score, however, specifically addresses patient selection for outpatient surgery. 

Other surgeons have also published their patient evaluation parameters for an outpatient setting. Shah et al. from Illinois excluded patients with a medical history and risk of clotting, major cardiovascular or cerebrovascular events, cardiac arrhythmias with a BMI ≥ 35, and insulin-dependent diabetes. 

Turcotte et al. disclosed their patient selection criteria for same-day discharge total joint arthroplasty patients: younger than 75 years of age, BMI < 35, no sleep apnea, no insulin-dependent diabetes, no significant cardiac conditions or recent cardiac procedure, no preoperative anemia, no history of urinary retention or benign prostatic hypertrophy, and deep vein thrombosis prophylaxis using a medication other than Coumadin. 

Patient selection is a significant part of the preoperative planning process to optimize patient safety but it is not the only important step. ASCs must invest in integrated technologies that streamline the entire TJA surgical planning process. 


Efficient Preoperative Planning for ASC joint surgeries

An average ASC can spend almost $1.5 million a year in operating expenses. A total joint procedure costs virtually the same in an ASC or a hospital setting. These costs include OR facilities, experienced surgeons, medical staff, robot-assisted, computer-assisted surgical tools, implant and instrument inventory, and other overhead. However, reimbursements are much lower for ASCs. This is why driving efficiencies in the process is critical to running an ASC cost-effectively

New technologies powered by artificial intelligence (AI) can be beneficial in this area. 


For example, end-to-end AI software can formulate entire surgical plans, including implant selection and positioning. AI can automatically generate accurate 3D models of patient anatomies to streamline the templating process through intelligent sizing. Integrated AI for preoperative planning also allows surgical teams to collaborate online for cases, make notes, and access this information right before or during surgery. Additionally, the use of patient-specific implants and instruments can significantly reduce costs and increase efficiency. 

Medical device companies can use this information to create process efficiencies on their end. Sizing implants and kitting the related instruments will be simpler. AI can enhance communication between surgical teams and medical device companies. With more accurate sizing and inventory planning, medical device companies can keep their costs low as they deal with higher caseloads but dwindling reimbursements. 

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