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Shifting Site of Service for Shoulder Replacements In Response to CMS Announcement

Based on the risk profiles of orthopaedic operations, a shoulder replacement is actually safer than that of a hip or knee and therefore an ideal candidate for the ambulatory surgical center environment.

As of January 1, primary shoulder replacements are approved by Centers for Medicare & Medicaid Services (CMS) to be performed in the ambulatory surgery center (ASC) environment. The CMS, in its wisdom, provided reasonable reimbursement rates to encourage the shift of the site of service for TSAs (Total Shoulder Arthroplasty)  from hospitals to the ASC for the appropriate patient. This is great news since the ASC is a safe, efficient, and typically cost-effective environment for shoulder replacements.

As more patients are eligible for shoulder replacement in an ASC environment, here’s what physicians should keep in mind to find the right patients, optimize perioperative protocols, and increase operating room efficiency as they transition more patients into ASCs.

Find the right patients

As lawmakers and administrators looked to accommodate patients outside of hospitals during the Covid-19 pandemic, eligibility criteria for ASCs relaxed. For example, age limits have been increased or removed entirely. Additionally, comorbidities that would have previously excluded a patient from outpatient surgery are now permitted in many facilities.

Over time, evidence has shown that outpatient surgery presents low stress to a patient’s physiology and is safe for a wider range of patients than what was previously thought. In fact, in my opinion, at least 60% of all patients needing shoulder arthroplasty are good candidates for the ASC environment. But which ones?

Through evidence-based research, doctors can better identify which patients are most suitable to sail through outpatient surgery without major complications—and this group is growing all the time.

There are a number of factors to consider when determining whether a patient should be treated in an ASC, but in general, the ideal patient:

  • Is 75 or younger
  • Is not anemic
  • Has good heart and lung function
  • Has no history of deep vein thrombosis (DVT)
  • Has a supportive recovery environment

Optimize perioperative protocols

Recent advancements in perioperative pain management have opened up ASCs to a much wider range of patients needing TSAs than previously thought possible.

Multimodal pain treatment

One of the most critical innovations to outpatient surgery is better pain control during and after surgery. Some patients are actually able to undergo TSA with little to no narcotics, making perioperative management much simpler. There are reports that up to a third of patients do not require narcotics after a shoulder replacement—which was unheard of even five years ago.

Multimodal pain treatment combines various groups of pain medications to provide patients with pain relief—resulting in the most effective pain management possible. Regional nerve blocks are now so effective that they can completely eliminate perioperative pain. Using long-acting agents, or even regular agents, along with certain adjuvant medications makes the nerve blocks last up to 24 hours. Another option to manage perioperative pain is periarticular injections, which involve administering analgesics into the tissues surrounding the surgical site.


Incredible advancements in anesthesia have been developed over the last ten years. A multimodal pain management approach that uses regional anesthesia can begin before the patient enters the surgery center and can continue after they go home. Overall, the ability to lower—or, in rare cases, eliminate—the need for general anesthesia opens up new possibilities for outpatient surgery. The better pain control described above means less anesthesia is required, which reduces related complications and increases the number of patients eligible for outpatient shoulder replacement.

Enhanced recovery after surgery (ERAS) protocols

Evidence-based perioperative measures are fueling the success of outpatient surgery. One of these measures is ERAS protocols, which involves:

  • Preoperative counseling
  • Nutrition optimization
  • Anesthetic regimens
  • Standardized analgesics
  • Early mobilization

When used together, these protocols ensure that patients who are treated in ASCs will receive the best care before, during, and after their surgery and help them achieve optimal recovery.

Increase operating room efficiency 

There are many ways to increase efficiency while reducing complications. Much hinges on effective staff training. When a surgeon has a team that is familiar with each other, they can learn to work together to perform the most efficient procedures possible.

Training should extend beyond the OR to those in administrative roles. Since a patient’s first and last interaction is with administrative staff, it’s important that these staff members are trained on how to efficiently handle patients while ensuring they receive the care they need.

Preoperative planning is also key to efficient operating. For example, templating and implant choice play a huge role in the success of ASC procedures. A customized surgery can be planned for each patient, which reduces cuts and shortens the time under anesthesia. At the same time, shoulder entry approaches are now more precise, thereby further reducing incisions and soft tissue damage. Additionally, smaller implants have been developed, allowing for more precise surgeries and shorter operating times.

Recently, digital technology has been added to the ASC environment by creating a dashboard where each patient is represented as an avatar. This provides a real-time assessment of the patient’s journey through the ASC, which allows all team members to anticipate the next task necessary to complete the patient’s surgical journey. This also provides the patient’s family with a real-time update of their progress.

The future of shoulder replacements

Based on the risk profiles of orthopaedic operations, a shoulder replacement is actually safer than that of a hip or knee and therefore an ideal candidate for the ASC environment. Today, if you ask a patient if they would rather have their procedure in the hospital or a surgery center, I’d estimate that 95% would rather have it in an ASC. There is clear alignment as far as patient satisfaction, high-quality perioperative care, surgeon preference, and efficient workflows.

I’ve personally seen the high patient satisfaction and amazing efficiency ASCs offer for shoulder replacements. I’m thrilled to now be able to also include my Medicare patients in my ASC practice.

Photo: nito100, Getty Images

Anthony Romeo, M.D., is one of the nation’s leading shoulder, elbow, and sports medicine surgeons with more than 27 years of clinical experience—15 of which were spent as a team physician for the Chicago White Sox, the Chicago Bulls, and as a consultant for numerous NFL, NCAA, and Olympic-level athletes. Having spent his career in the pursuit of excellence for his patients, Dr. Romeo has pioneered new approaches to shoulder replacement surgery and developed advanced orthopaedic implants and surgical procedures that are supported by cutting-edge research and patient-focused outcomes. Dr. Romeo is also the Executive Vice President of DuPage Medical Group’s state-of-the-art Musculoskeletal Institute and Chief Medical Editor of Orthopaedics Today.

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