August 2023

The surgical shift: Outpatient surgeries improve patient experience with similar or improved outcomes

The move exemplifies value-based care, checking all boxes for the triple aim: improving quality and outcomes, patient experience and cost savings.

Opting for outpatient

The advent of new technologies and minimally invasive techniques has made it possible for more surgeries to be performed on an outpatient basis. That means fewer procedures require a prolonged stay afterward – whether at the hospital or ambulatory surgical center. Instead, an increased number of patients are recovering at home after the effects of anesthesia wear off.

Data gathered by Cedar Gate Technologies from more than 12 million commercial insurance members show that inpatient surgeries decreased 7.33% from 2019 to 2021, while utilization rates for non-inpatient facilities increased. Hospital outpatient surgery volume increased 3.1%, and ambulatory surgical center utilization rates rose by 10.26%.

Experts say the greatest number of procedures shifting from inpatient to outpatient right now are concentrated in orthopedics, cardiology, and radiology service lines, including procedures like percutaneous coronary interventions (PCI), total hiparthroplasty (THA), total knee arthroplasty (TKA), spinal fusion, spinal decompression, and laparoscopic cholecystectomy (gallbladder removal). These procedures are more complex than those traditionally performed in ambulatory settings.

Additionally, patients requiring treatments like dialysis or infusions traditionally performed at outpatient centers are increasingly offered opportunities to receive these treatments in the privacy and comfort of their own homes.

 “In this era of care, we are seeing more procedures and treatments moving from inpatient to outpatient and from outpatient to home,” says Philip M. Oravetz, MD, MPH, Chief Population Health Officer at Ochsner Health. “Moving care, when appropriate, ‘checks all the boxes’ in terms of goals for value-based care. This transition often provides equal or better care quality and outcomes and greatly improves patients’ experience, and the side effect is lower cost. This transition is also a great way to engage specialists and community providers. They can help fuel the movement by assisting in the care redesign process.”

How Do Outpatient Surgeries, or Home Treatments, Meet the Definitions of Value-Based Care?

While outpatient options have been increasing for many years, the COVID-19 pandemic played a definite role in patient choice. Many avoided hospitals altogether in 2020 and 2021, opting to cancel or delay elective procedures due to fear of infection. Once these patients were ready to resume their treatment plan, they seemed to seek options that would keep them out of the hospital for an extended basis.

For many types of non-emergency surgeries, outpatient procedures offer patients the convenience and comfort of recovering at home. Because the patient is not spending time recovering in the hospital, the risk for a hospital-acquired infection is much, much lower.

Patients undergoing dialysis and certain infusions at home also report a much-improved experience, as the transition allows for the convenience of scheduling treatments that fit their routine and a greater degree of control and independence when it comes to managing their health. An environment that helps them feel comfortable and relaxed promotes healing, and they don’t have to worry about the stress of traveling to a center, giving them more time back to do the things they love. Certain types of home dialysis allow patients to sleep during the procedure or do more frequent, shorter treatments, both of which can improve patient outcomes and reduce dietary restrictions. Patient education, especially when it comes to proper safety and sanitation protocols is, of course, essential.

“By offering outpatient options for many of the surgeries our highly skilled providers perform, we are creating better patient outcomes and experiences at a lower cost, which also translates to shared savings for those surgical providers,” says Dr. Oravetz. “All of our surgeons use the latest tools, technologies and evidence-based protocols to determine if patients are eligible for outpatient procedures and deliver the highest quality care during those procedures. Patients can then recover in the comfort of home, surrounded by a familiar environment and the people they love, which most people prefer.”

Of course, some procedures cannot be performed on an outpatient basis, and if a patient has complex health issues that might put them at high risk, an inpatient surgery and stay might be the better option even an outpatient option is available. The same holds true with determining patient eligibility for at-home dialysis and infusions.

If a patient is eligible for an outpatient procedure, there is also always a small chance that a complication or emergency might make a transfer and an overnight stay necessary. But complications are uncommon, and a significant number of people each year undergo outpatient procedures.

At physician-owned ambulatory surgical centers, the surgeons and physicians have a great deal of control over how the center is used, who they hire, and what technologies and products they use. Because surgical patients are seen and treated in a controlled environment, these outpatient centers can use business intelligence and metrics to effectively measure the outcomes of surgical procedures and identify areas for improvement. Data-driven refinements to surgical techniques can reduce complications and improve patient outcomes. These are defining elements of value-based care.

Data collected by these outpatient centers also includes information about patient recovery times, patient education, pain management and what steps are taken after surgery (post-op care, rehabilitation and therapy, etc.). This patient health and satisfaction data helps inform future protocols, improve patient outcomes and reduce the risk of complications in defined populations.

There’s already been an aggressive move to outpatient for joint replacements, and other procedures are sure to follow.

“Same-day discharge hip and knee replacement had been going on for several years, but was not very widespread,” says George Chimento, MD, System Chair, Orthopedic Surgery at Ochsner Health. “When the Centers for Medicare & Medicaid Services took total knee replacement off the inpatient-only list, same-day joint replacement gained more traction. This was accelerated by the pandemic, as across the nation, hospital capacity was at a maximum, and they were filled with COVID patients.”

In order to be able to have hip or knee replacement surgery, patients needed to go home the same day.

“A study from the University of Utah showed that prior to the pandemic, 15% of their patients went home the same day. By the end of the pandemic, they were sending more than80% of patients home the same day,” Dr. Chimento says. “The key point here is that there was no decrease in quality, such as complications and readmissions.”

He says regional anesthesia, multimodal pain control and widespread adoption of tranexamic acid, which decreases blood loss, were the main factors that made the transition relatively seamless.  

“Surgeons had already developed tissue-sparing, less invasive techniques, and these other factors complemented those in such away that patients can be safely discharged on the same day,” Dr. Chimento says. “There are also obvious financial incentives for surgeons and hospitals to decrease the length of stay, and this shows that surgeons from both academic and private practice, as well physicians from different specialties, can work together for a common goal in safely redesigning care in a way that brings more value to patients as well as the healthcare system.” 

Physicians Are This Movement’s Natural Leaders

In all cases, providers need to meet at the table to understand which patients are the best candidates for either outpatient or home treatments.

“As chronic kidney disease prevalence increases, it becomes more important to find new and innovative ways to keep patients healthy and home,” says Sean Roberts, MD, a nephrologist at Ochsner. “Specifically, providing more dialysis services in the patient's home is a major step in improving the quality of life for ESRD patients and helps keep them with their families in familiar surroundings with the least impact on their quality of life.  Leveraging new technology along with our EMR is how we will achieve this goal to provide quality care in the comfort of the patient's home.”

“As providers, we have a responsibility to our patients to get involved in the care redesign process and help to move care when it’s appropriate,” adds Dr. Oravetz.

Article acknowledgements:
Thank you to OHN physicians who contributed their time and expertise to this article.

Meet Amanda Callegan-Poche’, MD,
Med-Peds physician

Amanda Callegan-Poche’, MD, says some of her most rewarding moments at work come when she can put a patient’s mind at ease. Whether it’s simplifying her description of a condition or diagnosis to ensure they understand it or celebrating their achievement of a lower A1C, Dr. Callegan-Poche’ says those are the moments that bring her joy.

“I’ve always loved helping people, and while I didn’t have family in the medical field, I was always drawn to the help doctors provided to various family members with health issues,” Callegan-Poche’ recalls. “I love kids, so I knew I wanted to pursue pediatrics. But I also found I really liked the complexity of internal medicine, working with older patients, and helping them manage conditions like hypertension and diabetes. I was thrilled when I found out I could do both.”

Callegan-Poche’s journey to becoming an Internal Medicine-Pediatrics (Med-Peds) provider began in the small, south Louisiana town of Plaquemine where she grew up. With only one pediatrician’s office in town, you can imagine how busy the doctors were. As a patient, the rushed feeling of her appointments never fazed her until she began having recurring headaches as a young teenager. She began to feel that her concerns weren’t being heard or addressed and asked her parents if she could find a new doctor.

“My new physician, Dr. Kevin Dean, really took the time to listen to me and address allof my concerns,” Callegan-Poche’ says. Ultimately, an MRI was ordered, and theyfound out she had atypical migraines. “My overall experience w sh a positive one. It felt good to be heard andto finally understand what was going on.” 

Dr. Dean was a Meds-Peds physician. “I don’t think he knows the impact he made on the trajectory of my career and how I practice medicine today! Maybe I should send him this article and let him know,” laughs Callegan-Poche’.

Today, Callegan-Poche’ sees patients three days a week and says making time to build and sustain a relationship with her patients is a top priority. Whether it’s anew patient or someone she’s cared for over many years, getting to know them on a personal level can often be the key to a successful diagnosis. Understanding their family dynamics, jobs and even what hobbies they enjoy provides invaluable insight and strengthens the doctor-patient connection.

“I’ve alwaysbeen a huge proponent of preventive care, so the recent industry shift to andfocus on keeping patients healthy and out of the hospital has been an intuitiveone for me,” Callegan-Poche’ says. She believes that if patients see theirphysicians regularly and get all their screenings done, they can prevent theearly onset of many illnesses and the bad outcomes that follow. She believesthat primary care physicians play an integral role in both preventive care andin coordinating whatever specialty care a patient may need.

Callegan-Poche’ says the resources she has access to through Ochsner Health Network help ensure her patients are getting the right care at the right time.

“Penny Parks, our clinical care coordinator, certainly makes my job a lot easier," Callegan-Poche’ says. “She goes through our patient lists and helps schedule important screenings like mammograms; she gets records release forms from patients and makes sure they get to me; she also sees to it that we’re meeting important care guidelines and quality measures. Our lead physician at Ochsner LSU Shreveport, Dr. [Lauren] Beal, has also been instrumental in providing educational opportunities to make these shifts as easy as possible for us. All-in-all, not much of my practice has changed because we were already paying attention to a lot of the preventive care guidelines.”

When she’s not seeing patients, she is teaching medical students and residents at Ochsner LSU Health Shreveport School of Medicine, a gig she enthusiastically accepted upon completion of her Med-Peds residency at the same school. “Teaching is another passion of mine. I tutored kids when I was in middle school, high school and even in college. Seeing that lightbulb moment never gets old, no matter what age the student is. It’s such a privilege to play a small part in their journey toward becoming a doctor!”

Dr. Callegan-Poche’ teaches medical students and Internal Medicine and Med-Peds residents and supervises residents in clinic a couple of days each week. “I enjoy helping prepare students and residents for their exams and helping them make connections between lectures and clinical experience,” she says. “Helping them learn how to be good doctors, how to listen to their patients and really understand their needs, is very rewarding.”

Fulfilling another lifelong dream, Dr. Callegan-Poche’ is also a mom. She shares three beautiful boys – Kinkade, 6, Kameron, 4 and Keegan, 6 months, with her husband, Kodi. The family loves visiting national parks “especially if mountains are involved," hiking and tending to a vegetable garden and a butterfly and hummingbird garden. Dr. Callegan-Poche’ also enjoys coaching her oldest son’s youth baseball team. “I’m the official coach and the unofficial team doctor!" she jokes.

If you would like to be featured in an upcoming OHN Physician Spotlight, or you’d like to recommend another provider with an interesting story to share, email carlie.boudreaux@ochsner.org
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Clinical Documentation Support

Coding Tip of the Month:
Chronic Obstructive Pulmonary Disease (COPD)

OHN provides the knowledge, resources, processes, and technology you need for success in value-based care so you can do more of what you love –taking care of patients. Each month, we share one coding tip and highlight one best practice advisory (BPA) to help to support your clinical documentation efforts.


Additionally, the clinical documentation excellence (CDE) team is here to support you – email riskadjustment@ochsner.org with any questions.

Capturing and Coding Chronic Obstructive Pulmonary Disease (COPD)

Rationale

-- Chronic obstructive pulmonary disease (COPD) is a broad term that represents a group of chronic, progressive lung diseases that obstruct the airways in the lungs, making it difficult to breathe.

-- There are two main types of COPD, and most people with COPD have a combination of both conditions:

  • Emphysema – a slowly progressive destruction of the lung tissue, which loses its elasticity and ability to expand and contract
  • Chronic bronchitis – a long-term, chronic inflammation and cough with mucus, resulting in narrowing and blockage of the airways

-- COPD includes a range of chronic, progressive, obstructive lung diseases usually caused by smoking and other environmental factors.

-- Bronchiectasis is NOT a type of COPD. COPD and bronchiectasis are two separate chronic lung conditions that can coexist. Although there are some similarities between the two, there also are some important differences and the conditions are treated differently.

-- Bronchiectasis is usually caused by inflammation and infection of the small airways (bronchi), which results in thickening and scarring of the airway walls. This airway damage prevents the natural clearing of mucus; thus, mucus accumulates and creates an environment in which bacteria can grow. This leads to a recurring cycle of inflammation and infection that can cause even more damage to the airways. Over time, the damaged airways lose their ability to effectively move air in and out, resulting in lack of adequate oxygen reaching vital organs. This can lead to serious health problems, such as respiratory failure and heart failure.

-- The American Hospital Association (AHA) Coding Clinic advises that COPD is a chronic, systemic condition that almost always affects patient care, treatment or management. Therefore, it is appropriate to document the COPD diagnosis in the final assessment as a current, coexisting condition, even in the absence of specific treatment of the condition on an individual date of service.

How To Code & Document

Subjective

  • In the subjective section of the office note, document the presence or absence of any current symptoms related to chronic obstructive pulmonary disease (such as shortness of breath, cough, fatigue, etc.).

Objective

  • The objective section should include all current associated physical exam findings (such as decreased breath sounds, wheezing, etc.) and related diagnostic test results, such as pulmonary function tests (PFT).

Assessment

  • Even when the COPD condition is being followed and managed by a different provider, it is important to include the diagnosis in the final assessment. For example: “Chronic emphysematous bronchitis followed and managed by pulmonologist, Dr. Jane Smith.”
  • Specificity: Describe each final COPD-related diagnosis to the highest level of specificity. A diagnosis of “COPD” is broad and nonspecific–it does not identify the particular type of COPD or any associated conditions. Include the current status (stable, worsening, improved, etc.)

Suspected vs. Confirmed

  • Do not document a suspected COPD condition as if it is confirmed. Instead, document the signs and symptoms in the absence of a confirmed diagnosis.
  • Do not describe a confirmed COPD diagnosis with terms that imply uncertainty (such as “probable,” “apparently,” “likely” or “consistent with”).

Treatment Plan

  • Documenta clear and concise treatment plan for COPD, linking related medications to the diagnosis.
  • Include orders for diagnostic testing.
  • Indicate in the office note to whom or where the referral or consultation requests are made.
  • Documentwhen the patient will be seen again, even if only on an as-needed basis.

Coding COPD

COPD and its associated conditions classify to the following categories:

  • J43 Emphysema
  • J44 Other chronic obstructive pulmonary disease
  • J45 Asthma

COPD classifies to category J44 with a fourth character required as follows to provide further specificity:

  • J44.Ø COPD with (acute) lower respiratory infection
  • J44.1 COPD with (acute) exacerbation
  • J44.9 Chronic obstructive pulmonary disease, unspecified
  • COPD with unspecified asthma is included in category J44 and codes to J44.9.

When the type of asthma is further specified, two codes are assigned: A code from category J44 for COPD; and a code from category J45 to report the type of asthma. Four-character subcategories under J45 include the following:

  • J45.2x Mild intermittent asthma
  • J45.3x Mild persistent asthma
  • J45.4x Moderate persistent asthma
  • J45.5x Severe persistent asthma
  • J45.9x Other and unspecified asthma

Fifth and sixth characters are added to report whether asthma is uncomplicated, with exacerbation or with status asthmaticus.

  • J45.9xOther and unspecified asthma

·COPD with acute bronchitis (an acute infection) is coded:

  • J44.Ø Chronic obstructive pulmonary disease with (acute) lower respiratory infection
  • J2Ø.9 Acute bronchitis, unspecified

Emphysema classifies to category J43 and is a more specific type of COPD. A fourth character is required to specify the particular type of emphysema.

  • J43.Ø Unilateral pulmonary emphysema (MacLeod’s syndrome)
  • J43.1 Panlobular emphysema
  • J43.2 Centrilobular emphysema
  • J43.8 Other emphysema
  • J43.9 Emphysema, unspecified

Please note:

  • Emphysema documented with coexisting chronic bronchitis classifies to category J44.
  • Emphysema without mention of chronic bronchitis classifies to category J43.

HCC Best Practice Advisory: Emphysema

To assist you in identifying patients with a potential emphysema (HCC 111) diagnosis, OHN’s Clinical Documentation Excellence (CDE) team, in collaboration with clinical leaders, have created a logic model within the HCC Best Practice Advisory (BPA) tool. The model uses natural language processing (NLP) in EPIC to identify potential diagnoses and present these within the BPA to you, the clinicians.

You can find information regarding suspected diagnoses within the EPIC “probable condition logic” hyperlink in the BPA, including the information listed below. In cases where NLP is used, a smart link will give you specific information concerning the suspected diagnosis, including the type of radiologic study, the date of the study, and a quote from the study which includes the word or statement that triggered the BPA tool.

HCC 111 Emphysema Logic Process Explained

If the radiologist’s reading of a CT image of the lungs includes words such as “emphysema” or “emphysematous,” a suspected diagnosis will be triggered.

Since this logic is based on string-matching algorithms of the imaging result, there could be a limited number of false positives if the radiologist’s reading contains the word “no” prior to the trigger words mentioned above.

If a patient meets both the emphysema and COPD logic, a suspected emphysema diagnosis will appear within the HCC BPA.

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