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November 26, 2018

As aging population boosts demand for orthopedic care, hospitals, others bet big on new outpatient facilities

HBJ Photo | Steve Laschever Dr. Andrew Caputo and the other 34 physicians who make up Orthopedic Associates of Hartford plan to open a 45,000-square-foot outpatient surgical center in Rocky Hill at an estimated $30 million cost.
HBJ Photo | Steve Laschever Orthopedic Associates’ outpatient surgery center is still under construction.
HBJ Photos | Sean Teehan Hartford HealthCare’s Bone and Joint Institute (top photo) opened in Jan. 2017. HHC President Jeffrey Flaks (left) shows off the institute’s musculoskeletal imaging center while physical therapist Stephanie Bourassa attends to a patient.

When Dr. Andrew Caputo underwent reconstructive surgery on his ACL 25 years ago, it was done as an inpatient procedure.

It was a hassle that required an overnight hospital stay to recover.

That knee surgery today, thanks to new technology and the healthcare system's push to move more care to lower-cost facilities, would likely be performed as an outpatient procedure, said Caputo, himself an orthopedic surgeon. So are an increasing number of surgeries like total joint replacements and some spinal procedures.

To accommodate that new reality, Caputo, along with the other 34 physicians who make up the independently owned Orthopedic Associates of Hartford, plan to open a new $30 million, 45,000-square-foot outpatient surgical center in Rocky Hill this January that will boost capacity and offer myriad services, including shoulder, knee and hip replacements.

And they aren't alone. Healthcare organizations across the state, ranging from large hospitals to independent practices, are investing tens of millions of dollars in new facilities for what is expected to be surging demand for outpatient orthopedics care.

Other examples include St. Francis Hospital and Medical Center, which broke ground in September on a $26.2 million, 35,000-square-foot orthopedic and pain ambulatory surgery center in Hartford.

Rendina Healthcare Real Estate is constructing a $25.3 million, 60,000-square-foot ambulatory care center in Bristol to be leased by Bristol Hospital for orthopedic and other services. Late last year, Stamford Hospital debuted a new orthopedic surgical unit it launched in partnership with New York's Hospital for Special Surgery.

And Hartford HealthCare opened its $150 million, 130,000-square-foot Bone and Joint Institute in early 2017.

“There's been a huge change in the types of procedures that are being done as an outpatient procedure versus an inpatient procedure,” Caputo said. “We have the capability of doing procedures that were previously inpatient … as outpatient.”

These big-ticket investments dovetail with increasing demand for orthopedic care, which experts expect to skyrocket over the next few decades as Connecticut's and the country's population ages and lives longer. More than 680,000 total knee replacements were performed in the United States in 2014, according to the latest data from the American Academy of Orthopaedic Surgeons (AAOS), a 5 percent increase from three years earlier.

Total knee replacements are projected to increase by 189 percent, to nearly 1.3 million, by 2030, and shoot up to about 2.6 million in 2060, according to AAOS projections.

In the Hartford market, the volume of outpatient joint replacements is projected to increase 227.1 percent over the next decade, while outpatient sports medicine and spine procedures are predicted to increase 43.9 percent and 27.5 percent, respectively, according to a recent analysis by Washington-D.C. consultancy Advisory Board.

Hospitals and other healthcare organizations are positioning themselves to get a healthy piece of that business.

As people live longer and stay more active later in life, sports-related and typical wear-and-tear injuries — like Achilles tendon and ACL ruptures or a meniscus tear — are becoming more prevalent, said Dr. Mariam Hakim-Zargar, owner of New England Orthopedic Center in Torrington and president of the Connecticut Orthopaedic Society.

Meantime, many of those injuries are being repaired by minimally invasive surgery techniques and technology housed in outpatient facilities, he said.

“That's not just a trend in Connecticut, that's (been happening) nationally, I'd say over the past 20 years,” Hakim-Zargar said.

Short visits

The shift among orthopedic surgeons to send patients home as quickly and safely as possible makes sense, considering the increasing number of surgery candidates, said Dr. Robert McAllister, St. Francis Hospital's director of operations for orthopedics and one of the principal investors in the hospital's new Orthopedic and Spine Surgery Center, a collaboration with Lighthouse Surgeons and Woodland Anesthesiology Associates.

Hospital bills grow exponentially with every day a patient spends recovering there, and with so many more people opting for orthopedic procedures, the cost of keeping them all hospitalized for as long as was once common would pose an unsustainable cost burden, McAllister said.

For example, he said, people getting joint replacement surgery in 1981 might have an eight-hour surgery followed by two weeks in the hospital, and further recovery in a nursing facility.

Today, a joint replacement surgery would take a few hours, and the patient could leave the same day, he said.

Like other new and under-construction facilities, St. Francis' will be set up with the intent to get patients out fast, McAllister said.

The center will house six orthopedic operating rooms, a procedure room and a 26-bay rehabilitation and physician space serving patients suffering from sports-related injuries, spine injuries, while also offering pain-management services.

“There's not a growing pot of money to take care of people, so as physicians, we need to figure out how to care for patients at a lower cost,” McAllister said.

But cost isn't the only consideration.

A 2011 study of patient outcomes at three hospitals in Syracuse, N.Y., demonstrated patients who have significantly longer hospital stays are more prone to complications — like attracting hospital-acquired infections — than those who left quicker.

“We want the patient to stay the shortest amount of time possible … to decrease the likelihood of complications,” McAllister said.

Preventative care

Hartford HealthCare's Bone and Joint Institute pairs its 14 operating rooms and 60 inpatient beds with facilities for physical therapy and preventative care.

Since the facility opened in Jan. 2017, doctors there have performed nearly 10,000 surgeries.

Patients from professional athletes whose livelihoods depend on their physical prowess to “weekend warriors” competing in Tough Mudders have used the Bone and Joint Institute's musculoskeletal imaging center, said Hartford HealthCare President Jeffrey Flaks. The center aims, in part, to help people avoid surgery by learning to move in ways that won't cause an injury in the first place.

In that room, patients can walk on a treadmill, swing a golf club or perform whatever motion they want to monitor. The motion is recorded by a dozen cameras, which convert the body to a skeletal image similar to a CAT scan. It shows how a patient moves, where those motions could cause tears or other problems and how to adjust movements to avoid those possible issues.

The University of Hartford's men's basketball team used the facility for all their pre-season screening, and for an NBA combine, Flaks said. So did a young man who wanted to join the military, but worried an ACL tear might take him out of the game. He's currently enrolled in an Army bridge program.

“This is a community resource, we built it with that in mind,” Flaks said. “It's a world-class capability, but we want to make it accessible to everybody.”

The Bone and Joint Institute aims to make Hartford HealthCare a destination for orthopedic surgery, Flaks said. Soon, however, they will see increased competition from their cross-town rival.

Meantime, about 75 percent of joint replacements — one of many orthopedic procedures — are performed at small and medium-sized hospitals (with less than 100 beds, and 400 beds, respectively), said Hakim-Zargar.

At Bristol Hospital, which has 106 beds, the number of orthopedic procedures shot up 66 percent to about 2,000 between 2016 and 2017, said James Diamond, senior practice administrator at Bristol Hospital Multi-Specialty Group.

That demand should be met by the new ambulatory care center the hospital will open, he said, hopefully by late May.

“We want to make sure that we can capture the needs of this community,” Diamond said.

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