Patient Preoperative Optimization: How to Do It and How to Be Paid for the Work

Preoperative optimization has become an essential component of the orthopaedic surgeon's workflow, especially as outpatient total joint arthroplasty (TJA) becomes more common in ambulatory surgery centers. Surgeons must identify and address modifiable patient risk factors, optimize surgical outcomes, and navigate reimbursement processes for these critical services.

This review outlines key aspects of preoperative optimization, including medical evaluations for anemia, glycemic control, smoking cessation, and the management of comorbidities like rheumatoid arthritis, obstructive sleep apnea, and peripheral vascular disease. Nutritional and obesity management, the perioperative use of glucagon-like peptide-1 agonists, and the decision-making process for inpatient versus outpatient surgery are also explored. Strategies for optimizing these factors and standardized protocols for risk stratification and patient selection are emphasized. In addition, the introduction of Principal Care Management codes is discussed as a pathway for surgeons to receive reimbursement for preoperative planning efforts.

Addressing modifiable risk factors reduces perioperative complications and improves outcomes. For example, tight glycemic control decreases the risk of periprosthetic joint infection, while smoking cessation enhances wound healing. Nutritional interventions, including addressing malnutrition and vitamin D deficiency, reduce complications. Obesity management strategies prioritize patient-centered approaches without strict body mass index cutoffs. Outpatient TJA has shown safety and feasibility and provided careful patient selection, facility readiness, and surgical efficiency. The Principle Care Management billing offers an opportunity for compensation for complex preoperative care.

Preoperative optimization is crucial for minimizing risks and improving outcomes in TJA, particularly as outpatient procedures become more prevalent. Surgeons play a pivotal role in managing patient factors, collaborating with consultants, and implementing standardized protocols. Embracing Principal Care Management codes acknowledges the extensive planning involved in optimizing safety and surgical outcomes, ensuring proper compensation while maintaining high standards of care.