From the Wall Street Journal, October 26, 2010
For Michael Noonan, knee surgery in April was practically a breeze—an outpatient procedure that had the 41-year-old investment banker hobbling home on crutches in a matter of hours after surgeon David Altchek replaced his anterior cruciate ligament using small incisions.
But recovery was another matter. He needed the crutches for three weeks, had 12 weeks of physical therapy three times a week, then six weeks of exercises at home. He rented a strap-on ice compression device to reduce swelling, and wore a brace for about five weeks. Though fully healed now, being responsible for so much of his own rehabilitation, he says, "was like taking a new baby home for the first time—you don't really feel like you're licensed to do it."
Surgery is easier and faster than ever before: Nearly 65% of all surgeries don't require an overnight hospital stay, compared to 16% in 1980. Hospitals that once kept patients for three weeks after some major operations now discharge them within a matter of days. But the body still heals at its own pace, and reduced time in hospital care means patients are assuming more responsibility for their own recovery—and more risks. Patients not only have to perform rehabilitation regimens at home, but they are more often caring for their own incision wounds and dressings and having to watch for signs of infections and blood clots. They also may be managing drains, implanted IV ports and pumps, all of which can be difficult and stressful.
The move to speedier surgeries is largely the result of new minimally invasive techniques, improvements in anesthesia and cost-cutting by insurance companies and hospitals. Surgical procedures now often use smaller incisions, cut less muscle, and result in less blood loss. Newer anesthetics allow patients to regain consciousness quickly or not go to sleep at all. Pain medications are more effective.
At the same time, concern about rising health care costs has led to changes in Medicare and insurance plans that have encouraged the development of outpatient surgical centers and created financial incentives for hospitals to shift less complex surgery to their own outpatient facilities. So, many types of surgeries previously performed in hospitals with overnight stays are now being done on an outpatient basis: The number of freestanding surgery centers grew from about 240 in 1983 to more than 5,000 now.
The mean charge for outpatient surgery was $6,100 versus $39,000 for inpatient surgery in 2007, according to the most recent report on surgical costs from the federal government. Insurance companies are also less likely to pay for stays at rehabilitation centers, places where surgical patients were often sent after hospital discharge to recuperate.
With patients going home so quickly, more are having to grapple with complications on their own. Of all the complications that occur in the 30 days after surgery, such as infection and blood clots, almost half will surface after a patient leaves the hospital, according to data from one million patients in a surgical quality improvement program sponsored by the American College of Surgeons.
"The onus is really on patients to recognize if something is a problem," says Clifford Ko, a colorectal surgeon at the University of California, Los Angeles, and director of research and optimal patient care for the American College of Surgeons. "The recovery period is often as important as the procedure itself, and patients who don't follow their discharge instructions could have longer recovery times, greater risk of a complication, and potentially more pain."
Knee surgery patients, for example, are counseled to maintain their weight after surgery. But a recent study shows that most patients gain weight, which can jeopardize the health of the other knee. Depression, another common after-surgery occurrence, also can inhibit healing, if patients don't seek treatment.
Efforts are underway to improve follow-up for patients, particularly those who have surgery in doctor's offices, which don't have the same regulation as outpatient surgery centers. The Institute for Safety in Office-Based Surgery has developed a checklist that includes assuring that discharge instructions are provided and a plan for follow-up care is clear. "Patients need to be asked things like if there is redness at the incision site, do you know what to do?" says Fred Shapiro, a Harvard anesthesiologist and president of the group. (Redness at an incision site can be a sign of infection.)
Infections that can occur after any surgery can lead to a severe bloodstream infection that can be fatal. A study published in July in the Journal of Hospital Infection of 84,000 patients who developed a surgical site infection found that more than half occurred after discharge, increasing the risks of an emergency room visit, readmission to the hospital, and another surgery.
For months after a procedure, surgical patients are also at high risk of developing blood clots which can travel to the lung and cause death from a pulmonary embolism. After joint replacement, for example, though the risk is greatest within two to five days, a second peak development period occurs about 10 days after surgery when most patients have been discharged from the hospital. In knee surgery patients, a clot can form in the calf if the patient fails to elevate the leg and perform specific movement exercises. Blood clots and subsequent pulmonary embolisms remain the most common cause for emergency readmission and death following joint replacement, according to the American Academy of Orthopaedic Surgeons.
The American Academy of Orthopaedic Surgeons sponsors workshops to teach its members better communications skills to help patients understand procedures and to stress the importance of follow-up care, such as providing clear written instructions and monitoring patients after surgery. "We can have a perfect total knee replacement but then have a poor outcome if we don't convince surgeons that explaining the post-operative care is in everyone's best interest," says John Tongue, a Portland, Ore.-area orthopedic surgeon and clinical associate professor at Oregon Health & Science University who teaches the workshops.
Insurers have become stricter about paying for inpatient rehabilitation programs where surgical patients were once transferred to recover. The move has been spurred partly by studies that show that cheaper at-home visits from therapists are effective.
But Nina Reznick, a 63-year old patient who had both hips replaced last July, says the home therapist her insurance paid for did not have the equipment or time to really help, so she did extra exercises on her own. She believes that effort enabled her to walk a week after surgery. "You are really on your own, and you have to be very motivated," she says.
Some doctors say that the changing demographics of their patients also can contribute to bumpy recoveries. Dr. Altchek, who performs knee and rotator cuff surgery at the Hospital for Special Surgery in New York, says that more younger patients are opting to replace troublesome knees and hips so they can resume athletic activities such as tennis and skiing; close to 42% of all knee replacements in 2008 were for patients aged 45 to 65, compared to less than 35% in 2002, and studies show that waiting too long once a joint starts to deteriorate before having surgery can make recovery more difficult.
But younger patients may also be impatient and assume they are healed, and then quit rehabilitation too early, Dr. Altchek says.
Andrew Minko, a 41-year-old patient of Dr. Altchek's who plays tennis and surfs, has had two surgeries to repair joints on his left shoulder and now needs surgery on his right shoulder. Though he healed well, he admits he was somewhat lax about doing his exercises at home and may have rushed into some activities too quickly after the previous procedures. For the upcoming surgery, he says, "I will be more diligent about the recovery."
