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Name:
Outpatient Hip and Knee Arthroplasty in a Freestanding Facility
Description:
Outpatient Hip and Knee Arthroplasty in a Freestanding Facility
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Upload Date:
2024-05-31T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
KEITH BEREND: Hi. My name is Keith Berend. I'm an orthopedic surgeon in New Albany, Ohio, which is outside of Columbus, Ohio in the Midwest. I'm honored to have been invited to give a presentation today specifically addressing outpatient hip and knee arthroplasty in a freestanding ambulatory surgery facility. How are things doing on this side of the pond? I do have a conflict of interest with SurgCenter Development, I'm a development partner, and we're going to talk specifically about that development model.
KEITH BEREND: We're not, in the United States, one of the things that's really come about, not just with COVID, but this data is pre-COVID. This is from 2017 where we've seen a significant cost savings and a significant reduction in the complication rate by moving arthroplasty of the hip and knee to the outpatient space. And interestingly this isn't data from GIS orthopedics, this is data from the largest health care insurer in the United States.
KEITH BEREND: This would be Anthem Blue Cross Blue Shield. And so they're very aware of the way that we can save money in the outpatient space doing hip and knee arthroplasty. The key, or the critical component, to being successful in the ambulatory surgery center however, is the capacity to have efficiency. And efficiency is defined as the capacity to produce a desired result with a minimal expenditure of energy, money, time, and materials.
KEITH BEREND: So if you think about it, performing these sort of major orthopedic surgeries in the outpatient space is really the best way to reduce the energy, the expenditure, the money, the time, and the materials needed to perform these surgeries. You don't need a giant hospital and all that goes into maintaining a hospital in order to perform these safely. Our model is a physician-owned development partner model where we utilize a very small footprint.
KEITH BEREND: Usually our centers are 7,000 to 7,500 square feet. Two ORs and one minor procedure room. Five or six pre-op or PACU bays, recovery room bays. One to two overnight beds depending on where that's applicable. There are some state regulations in terms of who can stay overnight and how many beds you can have. It's definitely not mandatory as I'll show you some of our data. Early on some patients stayed overnight, and now in the last couple of years really no one stays overnight.
KEITH BEREND: Ideally we find an existing shell that's capable of holding this type of facility. And if so it takes us about nine to 11 months to open and start operating. If we have to build a building it usually takes about 12 to 14 months. So this is our model. This is our footprint for building an efficient ambulatory surgery center.
KEITH BEREND: The most important thing as I mentioned, is to have a culture of efficiency. And this starts with the surgeon. The surgeon has to have the perspective of being efficient. We have to have accurate pre-op planning and templating, effective utilization of the pre-op holding area. And what we mean by that is anesthesia, preoperatively, is administered in the pre-op area.
KEITH BEREND: Not in the operating room. As my mentor Dr. Mallory used to say, the operating room is for operating, not for administering the spinal, or the block, or the anesthesia. That is all done in the pre-op holding area. You need to develop very accurate surgeon preference cards and they need to be updated if you change anything. Streamline instrument sets, and I'm specifically going to talk about that.
KEITH BEREND: OR setup protocols. It's a team concept. No one in the room is above having to mop the floor at the end of a case or move dirty instruments to the dirty instrument room. We consistently want to look at the operative workflow and make sure that we're being efficient. And then standardize the closure and the dressings so that we know what sutures, or if we're going to use a negative pressure wound dressing, or we're going to use a silver dressing, we know who's going to receive that and we do it the same way every time.
KEITH BEREND: As I said, effective utilization in the pre-op holding area. We eliminate unnecessary traffic while instruments are being opened. That way the room is being prepared for the surgery while the patient is being prepared for the surgery in the pre-op holding area. From the surgeon's perspective, I'm not sure who actually I should quote for this. I think Dr. Booth, Dr. Lombardi, and Dr. Mallory all have lived a practice that really, it's not about speed.
KEITH BEREND: It's about choreography. And everyone knows how efficient Dr. Booth and Lombardi and Mallory are in the OR. It isn't because they're fast surgeons. It's because they've got an incredible team that knows the choreography of the operation, down to how to hand an instrument. Where to put the instrument down when you're done. And so it's not about being fast to be efficient, it's about using good choreography with your team.
KEITH BEREND: And then what about the instruments? We only open the basic instruments onto the tables as you see here. So every operation, whether it's a hip, a knee, it can be done with only two trays for every case. Then the vendors are only allowed two trays for every case as well. Well how is that possible if we've got a Persona knee or a Stryker knee that's going to require 10 or 12 trays?
KEITH BEREND: Well how that's possible is we only open the basic instruments that are used in every single case. Like the distal femoral cutting guide and the tibial cutting guide for example. And then the femoral alignment and measuring device. Whether you use anterior referencing, posterior referencing, whatever. You're going to open that instrument onto the field. And then once you've sized the femur, for example, in a total knee, why do you need to have, if you're doing a left total knee in a woman, why do you need to have the 72.5 right trial on the table?
KEITH BEREND: You don't need it. And so all of the guides, all the instruments, anything that's size or side specific, trials, instruments, cutting guides, et cetera, they're all wrapped in a separate package. As you can see in the lower right hand corner, this is the tibial trials. We don't need a size 83 open on the table if we know we're going to use a size 71, for example.
KEITH BEREND: And so these are open sterilely onto the table during the procedure to avoid having to re-sterilize and reconvene all these trays. It makes for an incredibly efficient way to do these procedures. One of the things that I'm constantly asked is, well, how do you know who's a candidate for the operation. And the way that we know is we're going to look at each individual patient and we're going to say, does the patient have a problem that cannot be optimized.
KEITH BEREND: And if they cannot, or if they cannot be optimized, then the surgery is delayed until they're medically optimized. Next step, does the patient have an organ failure. And by that I mean literally, do they have heart failure. Do they have COPD such that they need oxygen? Do they have renal failure to where they're on dialysis? Do they have hepatic failure to where they have cirrhosis? Do they have a brain failure where they have significant dementia?
KEITH BEREND: Do they have peripheral neuropathy or nerve failure that's severe enough that their non-ambulatory or they have trouble functioning? If they do not have an organ failure, then we move on to the green. If they do have an organ failure, the patient may not be a candidate for outpatient surgery. If that organ failure is medically stable, we would perform that procedure in the hospital, and then the patient could be observed for 23 hours or put in an intensive care unit or consultants can be advising their care.
KEITH BEREND: But if they don't have an organ failure, then the next question is do they have adequate support at home for discharge. Who's going to be at home with them? Their living environment really doesn't matter that much. And the reason I say that is in New York, for example, many, many patients live alone and are in a two or three story walk up. Well they're doing that with a bad knee already.
KEITH BEREND: They're going to be able to function OK to be safe at home as long as they have someone to help them. And so if they have adequate support, they don't have an organ failure, and they're medically optimized, every one of those patients is done in our surgery center. Again, if they don't have enough support at home where they may need to go to a rehab center post discharge, we would consider doing their procedure at the hospital.
KEITH BEREND: Well how does it work and does it work? We opened our orthopedic specialty freestanding ambulatory surgery center, no connection to a hospital, it's just it's actually in our office building, in June of 2013. And as of September of 2020, the five surgeons in JIS had performed at 10,100 hip, knee, and shoulder arthroplasties at our freestanding facility. You can see here 2,800 partial knees, as you know we're big fans of the partial knee here in New Albany.
KEITH BEREND: 4,000 primary total knees. 219 revision hips and knees, and I'm specifically going to talk a little bit about revision knees. And then almost 3,000 primary total hips. The approach I will mention doesn't really matter. I happen to do anterior approach on hips on everyone. Two of my partners do a spattering of direct lateral. And again for revision hips I've done giant direct laterals and big posteriors.
KEITH BEREND: Femoral revisions, acetabular revisions. The approach doesn't really matter. It's how the patients are cared for. And then 80 total shoulders are reversed shoulder arthroplasties. Over that seven year period roughly, 96% of patients are discharged home the same day. 0.25%, a quarter of 1%, of patients required calling an ambulance and being transferred to an acute care hospital.
KEITH BEREND: That could be for new onset atrial fibrillation, some type of other new onset arrhythmia. It could be flash pulmonary edema upon extubation in some patients, I mentioned cardiac arrhythmia, but chest pain and a positive EKG change. But the point is that it's 25 out of 10,000. So it's incredibly safe. That safety margin is about the same as if you were doing arthroscopic surgery or EMT type surgeries at a freestanding facility.
KEITH BEREND: About 4% stayed overnight over the entire period of time out of 10,000. One and 1/2 percent of those, or 142, stayed for convenience. Later in the day, wife doesn't want to drive at night, live far away, medical tourism, et cetera. And then 2.75% of patients stayed for some type of medical reason. The most common was obstructive sleep apnea and difficulty weaning from oxygen. And so if you don't have the capability of keeping someone overnight, you don't necessarily do obese patients with obstructive sleep apnea at the freestanding facility because those are the patients that are at the highest risk of having to stay overnight.
KEITH BEREND: Things like urinary retention. When we first started out, we would keep those patients overnight with a catheter and pull it out the next day. Now we would just send the patient home with the catheter and a referral to their urologist. I'm going to give you a little bit of data. This was the first article that we published. I know this is about hip but it just is basically to show you that total hip replacement, very easily done.
KEITH BEREND: Major complications that occurred within 48 hours, three out of 1,000. And so the reason that's important is those maybe are the ones that you could have detected or seen if the patient was in the hospital. None of those were fatal complication. And interestingly 2.2% 90 day complication rate. If you compare that, or readmission rate, if you compare that with some of the data from the bundles from Lowry Barnes out of Arkansas, they reduced theirs from in the teens down to in the high single digits.
KEITH BEREND: So 7% to 8%. We're talking about 2.2%. Yes, these are selected patients. But they're not that well selected. As I mentioned, they are medically optimized. They don't have an organ failure and they have support at home. Otherwise they're being done at the Center. And so they're not that cherry picked in terms of medical complications.
KEITH BEREND: I mentioned the number of outpatient revision knee arthroplasties that we've done. This number has increased significantly since 2018 when this data came out. Particularly again with COVID shutting down some of the procedures in the hospital for a period of time in 2020. But as of this publication which we published in JoA last year, we had done 106 revision total knees and 102 patients.
KEITH BEREND: To look at the big picture, that represents about 2% of the knee surgeries that were done at the surgery center during that period of time. And so we did about 5,000 knees and 2% of those were revisions. It represents about 8% of the revision arthroplasties that were done by our practice. We did 13 revisions during that five year time frame, 4 and 1/2 year time frame. And that represents about 8% of them.
KEITH BEREND: So it's a pretty good chunk of the revision arthroplasties. Admittedly these are routinely going to be polyethylene change for instability. They're going to be revision of a uni to a total. Although unis rarely ever fail, but we've done enough that we will see some failures. But we've done big cone stem revisions. Doctor Lombardi in particular did a big hinge revision. A lot of it in our environment in North America, or at least in the United States, also depends on the payer.
KEITH BEREND: So in the hospital, the hospitals will sometimes have contracts where the payers will reimburse for the implant cost. If that's not the case in the surgery center, some of the big revisions with cones, hinges, constraint stems, augments, et cetera, would need to be done at the hospital strictly because of the cost is better in the hospital. They have a better reimbursement than we do at the surgery center.
KEITH BEREND: The demographics evenly split between men and women. Relatively young age although up to 74. Mean height is what you expect. Weight is what you expect for American population and the BMI as well, from 19 to notice 56 in one of the patients. Well how'd they do? We had no major complications within the first 48 hours. So there was no reason for them to have been done at the hospital.
KEITH BEREND: Out of these 100 plus patients we had one readmission at 11 days for ileus. There were no deaths and no other surgical complications or re-operations within the first three months. And so it's perfectly safe to be done. What kind of procedures do we do? Well we'll do a simple revision for instability, we'll do a revision of a uni to a total knee. But the things we won't do obviously, both magnitude of surgery and cost would be things like a total femoral replacement, hinge knees with big augments, et cetera.
KEITH BEREND: Is this just JIS Orthopedics in just central Ohio? The answer is no. SurgCenter Development, who we work with, over the seven year period that I'm reporting on, has 122 facilities in 21 states that are performing joint replacement. Again 2020 increased that number substantially. It's a standardized surgeon-modifiable program. Meaning we help you develop these programs. We've performed over 55,000 joint replacements in these centers.
KEITH BEREND: The length of stay is measured in hours, not days. The length of stay on average for total knee replacement is four hours. 97% of 55,000 patients were able to go home the same day. The overall readmission rate is 0.4% and the infection rate is a quarter of 1%. So it is scalable. It is applicable. It's safe.
KEITH BEREND: And it at least in our environment, in the United States, is very, very easy to be done and is certainly where not only the trend, but I think the train has arrived. The other thing about this model is that it can build real equity. It's never the intent of the system to sell to a larger entity, but the development partner that we've worked with has a long history of producing efficient, highly profitable centers and publicly traded companies like Tenet USPI will be very interested in their investment portfolio and their management portfolio.
KEITH BEREND: We were fortunate to have been involved in this Tenet purchase of 45 surgery centers at the end of 2020, and that was a $1.1 billion US deal. And so this is a way to really build equity, unlike partnering with a hospital, or joint venture, or starting out with a publicly traded company. Or starting out with a smaller, less experienced company that can't build this equity with their surgeon partners. And so, this to me is the ideal model for performing outpatient joint replacements.
KEITH BEREND: I will say in conclusion, the most important thing that I've learned, despite us being very early on in this trend, we started in June of 2013, is that patients really, really like this. They like the accountability on behalf of the surgeons as the owners and managers of these facilities. You know it was a thought and I heard early in our debates at the Academy, and at CCJR, well you're kicking patients out.
KEITH BEREND: They and their families are not going to be happy. Well we've maintained over 10,000 patients a 98% good to excellent satisfaction rating for the care that they were provided. It's significantly more patient-focused, one-on-one care than in a hospital. Significantly less medical errors. Significantly lower risk of infection. And so the most important thing that I've learned in all of this is patients absolutely love it.
KEITH BEREND: And I as the surgeon caregiver absolutely love the autonomy and the accountability that comes with being a surgeon owner in a development-partner model, freestanding ambulatory surgery center performing hip and knee arthroplasty. Thank you very much.
Segment:0 .
KEITH BEREND: Hi. My name is Keith Berend. I'm an orthopedic surgeon in New Albany, Ohio, which is outside of Columbus, Ohio in the Midwest. I'm honored to have been invited to give a presentation today specifically addressing outpatient hip and knee arthroplasty in a freestanding ambulatory surgery facility. How are things doing on this side of the pond? I do have a conflict of interest with SurgCenter Development, I'm a development partner, and we're going to talk specifically about that development model.
KEITH BEREND: We're not, in the United States, one of the things that's really come about, not just with COVID, but this data is pre-COVID. This is from 2017 where we've seen a significant cost savings and a significant reduction in the complication rate by moving arthroplasty of the hip and knee to the outpatient space. And interestingly this isn't data from GIS orthopedics, this is data from the largest health care insurer in the United States.
KEITH BEREND: This would be Anthem Blue Cross Blue Shield. And so they're very aware of the way that we can save money in the outpatient space doing hip and knee arthroplasty. The key, or the critical component, to being successful in the ambulatory surgery center however, is the capacity to have efficiency. And efficiency is defined as the capacity to produce a desired result with a minimal expenditure of energy, money, time, and materials.
KEITH BEREND: So if you think about it, performing these sort of major orthopedic surgeries in the outpatient space is really the best way to reduce the energy, the expenditure, the money, the time, and the materials needed to perform these surgeries. You don't need a giant hospital and all that goes into maintaining a hospital in order to perform these safely. Our model is a physician-owned development partner model where we utilize a very small footprint.
KEITH BEREND: Usually our centers are 7,000 to 7,500 square feet. Two ORs and one minor procedure room. Five or six pre-op or PACU bays, recovery room bays. One to two overnight beds depending on where that's applicable. There are some state regulations in terms of who can stay overnight and how many beds you can have. It's definitely not mandatory as I'll show you some of our data. Early on some patients stayed overnight, and now in the last couple of years really no one stays overnight.
KEITH BEREND: Ideally we find an existing shell that's capable of holding this type of facility. And if so it takes us about nine to 11 months to open and start operating. If we have to build a building it usually takes about 12 to 14 months. So this is our model. This is our footprint for building an efficient ambulatory surgery center.
KEITH BEREND: The most important thing as I mentioned, is to have a culture of efficiency. And this starts with the surgeon. The surgeon has to have the perspective of being efficient. We have to have accurate pre-op planning and templating, effective utilization of the pre-op holding area. And what we mean by that is anesthesia, preoperatively, is administered in the pre-op area.
KEITH BEREND: Not in the operating room. As my mentor Dr. Mallory used to say, the operating room is for operating, not for administering the spinal, or the block, or the anesthesia. That is all done in the pre-op holding area. You need to develop very accurate surgeon preference cards and they need to be updated if you change anything. Streamline instrument sets, and I'm specifically going to talk about that.
KEITH BEREND: OR setup protocols. It's a team concept. No one in the room is above having to mop the floor at the end of a case or move dirty instruments to the dirty instrument room. We consistently want to look at the operative workflow and make sure that we're being efficient. And then standardize the closure and the dressings so that we know what sutures, or if we're going to use a negative pressure wound dressing, or we're going to use a silver dressing, we know who's going to receive that and we do it the same way every time.
KEITH BEREND: As I said, effective utilization in the pre-op holding area. We eliminate unnecessary traffic while instruments are being opened. That way the room is being prepared for the surgery while the patient is being prepared for the surgery in the pre-op holding area. From the surgeon's perspective, I'm not sure who actually I should quote for this. I think Dr. Booth, Dr. Lombardi, and Dr. Mallory all have lived a practice that really, it's not about speed.
KEITH BEREND: It's about choreography. And everyone knows how efficient Dr. Booth and Lombardi and Mallory are in the OR. It isn't because they're fast surgeons. It's because they've got an incredible team that knows the choreography of the operation, down to how to hand an instrument. Where to put the instrument down when you're done. And so it's not about being fast to be efficient, it's about using good choreography with your team.
KEITH BEREND: And then what about the instruments? We only open the basic instruments onto the tables as you see here. So every operation, whether it's a hip, a knee, it can be done with only two trays for every case. Then the vendors are only allowed two trays for every case as well. Well how is that possible if we've got a Persona knee or a Stryker knee that's going to require 10 or 12 trays?
KEITH BEREND: Well how that's possible is we only open the basic instruments that are used in every single case. Like the distal femoral cutting guide and the tibial cutting guide for example. And then the femoral alignment and measuring device. Whether you use anterior referencing, posterior referencing, whatever. You're going to open that instrument onto the field. And then once you've sized the femur, for example, in a total knee, why do you need to have, if you're doing a left total knee in a woman, why do you need to have the 72.5 right trial on the table?
KEITH BEREND: You don't need it. And so all of the guides, all the instruments, anything that's size or side specific, trials, instruments, cutting guides, et cetera, they're all wrapped in a separate package. As you can see in the lower right hand corner, this is the tibial trials. We don't need a size 83 open on the table if we know we're going to use a size 71, for example.
KEITH BEREND: And so these are open sterilely onto the table during the procedure to avoid having to re-sterilize and reconvene all these trays. It makes for an incredibly efficient way to do these procedures. One of the things that I'm constantly asked is, well, how do you know who's a candidate for the operation. And the way that we know is we're going to look at each individual patient and we're going to say, does the patient have a problem that cannot be optimized.
KEITH BEREND: And if they cannot, or if they cannot be optimized, then the surgery is delayed until they're medically optimized. Next step, does the patient have an organ failure. And by that I mean literally, do they have heart failure. Do they have COPD such that they need oxygen? Do they have renal failure to where they're on dialysis? Do they have hepatic failure to where they have cirrhosis? Do they have a brain failure where they have significant dementia?
KEITH BEREND: Do they have peripheral neuropathy or nerve failure that's severe enough that their non-ambulatory or they have trouble functioning? If they do not have an organ failure, then we move on to the green. If they do have an organ failure, the patient may not be a candidate for outpatient surgery. If that organ failure is medically stable, we would perform that procedure in the hospital, and then the patient could be observed for 23 hours or put in an intensive care unit or consultants can be advising their care.
KEITH BEREND: But if they don't have an organ failure, then the next question is do they have adequate support at home for discharge. Who's going to be at home with them? Their living environment really doesn't matter that much. And the reason I say that is in New York, for example, many, many patients live alone and are in a two or three story walk up. Well they're doing that with a bad knee already.
KEITH BEREND: They're going to be able to function OK to be safe at home as long as they have someone to help them. And so if they have adequate support, they don't have an organ failure, and they're medically optimized, every one of those patients is done in our surgery center. Again, if they don't have enough support at home where they may need to go to a rehab center post discharge, we would consider doing their procedure at the hospital.
KEITH BEREND: Well how does it work and does it work? We opened our orthopedic specialty freestanding ambulatory surgery center, no connection to a hospital, it's just it's actually in our office building, in June of 2013. And as of September of 2020, the five surgeons in JIS had performed at 10,100 hip, knee, and shoulder arthroplasties at our freestanding facility. You can see here 2,800 partial knees, as you know we're big fans of the partial knee here in New Albany.
KEITH BEREND: 4,000 primary total knees. 219 revision hips and knees, and I'm specifically going to talk a little bit about revision knees. And then almost 3,000 primary total hips. The approach I will mention doesn't really matter. I happen to do anterior approach on hips on everyone. Two of my partners do a spattering of direct lateral. And again for revision hips I've done giant direct laterals and big posteriors.
KEITH BEREND: Femoral revisions, acetabular revisions. The approach doesn't really matter. It's how the patients are cared for. And then 80 total shoulders are reversed shoulder arthroplasties. Over that seven year period roughly, 96% of patients are discharged home the same day. 0.25%, a quarter of 1%, of patients required calling an ambulance and being transferred to an acute care hospital.
KEITH BEREND: That could be for new onset atrial fibrillation, some type of other new onset arrhythmia. It could be flash pulmonary edema upon extubation in some patients, I mentioned cardiac arrhythmia, but chest pain and a positive EKG change. But the point is that it's 25 out of 10,000. So it's incredibly safe. That safety margin is about the same as if you were doing arthroscopic surgery or EMT type surgeries at a freestanding facility.
KEITH BEREND: About 4% stayed overnight over the entire period of time out of 10,000. One and 1/2 percent of those, or 142, stayed for convenience. Later in the day, wife doesn't want to drive at night, live far away, medical tourism, et cetera. And then 2.75% of patients stayed for some type of medical reason. The most common was obstructive sleep apnea and difficulty weaning from oxygen. And so if you don't have the capability of keeping someone overnight, you don't necessarily do obese patients with obstructive sleep apnea at the freestanding facility because those are the patients that are at the highest risk of having to stay overnight.
KEITH BEREND: Things like urinary retention. When we first started out, we would keep those patients overnight with a catheter and pull it out the next day. Now we would just send the patient home with the catheter and a referral to their urologist. I'm going to give you a little bit of data. This was the first article that we published. I know this is about hip but it just is basically to show you that total hip replacement, very easily done.
KEITH BEREND: Major complications that occurred within 48 hours, three out of 1,000. And so the reason that's important is those maybe are the ones that you could have detected or seen if the patient was in the hospital. None of those were fatal complication. And interestingly 2.2% 90 day complication rate. If you compare that, or readmission rate, if you compare that with some of the data from the bundles from Lowry Barnes out of Arkansas, they reduced theirs from in the teens down to in the high single digits.
KEITH BEREND: So 7% to 8%. We're talking about 2.2%. Yes, these are selected patients. But they're not that well selected. As I mentioned, they are medically optimized. They don't have an organ failure and they have support at home. Otherwise they're being done at the Center. And so they're not that cherry picked in terms of medical complications.
KEITH BEREND: I mentioned the number of outpatient revision knee arthroplasties that we've done. This number has increased significantly since 2018 when this data came out. Particularly again with COVID shutting down some of the procedures in the hospital for a period of time in 2020. But as of this publication which we published in JoA last year, we had done 106 revision total knees and 102 patients.
KEITH BEREND: To look at the big picture, that represents about 2% of the knee surgeries that were done at the surgery center during that period of time. And so we did about 5,000 knees and 2% of those were revisions. It represents about 8% of the revision arthroplasties that were done by our practice. We did 13 revisions during that five year time frame, 4 and 1/2 year time frame. And that represents about 8% of them.
KEITH BEREND: So it's a pretty good chunk of the revision arthroplasties. Admittedly these are routinely going to be polyethylene change for instability. They're going to be revision of a uni to a total. Although unis rarely ever fail, but we've done enough that we will see some failures. But we've done big cone stem revisions. Doctor Lombardi in particular did a big hinge revision. A lot of it in our environment in North America, or at least in the United States, also depends on the payer.
KEITH BEREND: So in the hospital, the hospitals will sometimes have contracts where the payers will reimburse for the implant cost. If that's not the case in the surgery center, some of the big revisions with cones, hinges, constraint stems, augments, et cetera, would need to be done at the hospital strictly because of the cost is better in the hospital. They have a better reimbursement than we do at the surgery center.
KEITH BEREND: The demographics evenly split between men and women. Relatively young age although up to 74. Mean height is what you expect. Weight is what you expect for American population and the BMI as well, from 19 to notice 56 in one of the patients. Well how'd they do? We had no major complications within the first 48 hours. So there was no reason for them to have been done at the hospital.
KEITH BEREND: Out of these 100 plus patients we had one readmission at 11 days for ileus. There were no deaths and no other surgical complications or re-operations within the first three months. And so it's perfectly safe to be done. What kind of procedures do we do? Well we'll do a simple revision for instability, we'll do a revision of a uni to a total knee. But the things we won't do obviously, both magnitude of surgery and cost would be things like a total femoral replacement, hinge knees with big augments, et cetera.
KEITH BEREND: Is this just JIS Orthopedics in just central Ohio? The answer is no. SurgCenter Development, who we work with, over the seven year period that I'm reporting on, has 122 facilities in 21 states that are performing joint replacement. Again 2020 increased that number substantially. It's a standardized surgeon-modifiable program. Meaning we help you develop these programs. We've performed over 55,000 joint replacements in these centers.
KEITH BEREND: The length of stay is measured in hours, not days. The length of stay on average for total knee replacement is four hours. 97% of 55,000 patients were able to go home the same day. The overall readmission rate is 0.4% and the infection rate is a quarter of 1%. So it is scalable. It is applicable. It's safe.
KEITH BEREND: And it at least in our environment, in the United States, is very, very easy to be done and is certainly where not only the trend, but I think the train has arrived. The other thing about this model is that it can build real equity. It's never the intent of the system to sell to a larger entity, but the development partner that we've worked with has a long history of producing efficient, highly profitable centers and publicly traded companies like Tenet USPI will be very interested in their investment portfolio and their management portfolio.
KEITH BEREND: We were fortunate to have been involved in this Tenet purchase of 45 surgery centers at the end of 2020, and that was a $1.1 billion US deal. And so this is a way to really build equity, unlike partnering with a hospital, or joint venture, or starting out with a publicly traded company. Or starting out with a smaller, less experienced company that can't build this equity with their surgeon partners. And so, this to me is the ideal model for performing outpatient joint replacements.
KEITH BEREND: I will say in conclusion, the most important thing that I've learned, despite us being very early on in this trend, we started in June of 2013, is that patients really, really like this. They like the accountability on behalf of the surgeons as the owners and managers of these facilities. You know it was a thought and I heard early in our debates at the Academy, and at CCJR, well you're kicking patients out.
KEITH BEREND: They and their families are not going to be happy. Well we've maintained over 10,000 patients a 98% good to excellent satisfaction rating for the care that they were provided. It's significantly more patient-focused, one-on-one care than in a hospital. Significantly less medical errors. Significantly lower risk of infection. And so the most important thing that I've learned in all of this is patients absolutely love it.
KEITH BEREND: And I as the surgeon caregiver absolutely love the autonomy and the accountability that comes with being a surgeon owner in a development-partner model, freestanding ambulatory surgery center performing hip and knee arthroplasty. Thank you very much.
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