Newsletter and Subscription Sign Up

AVATAR: Helping with Outpatient Joint Replacement

Published Monday May 17, 2021

Author Dr. Thomas V. King & Dr. Moby Parsons/Knee Hip Shoulder Center

This is a sponsored supplement, which first appeared in Business NH Magazine's Health Care Handbook in the April 2021 issue.

As the percentage of the U.S. population 65 and older has progressively increased, the demand for joint replacement surgery has steadily risen over the past 2 decades with over 1 million hip and knee replacements performed annually. This number is projected to increase to 4 million by 2030 with the fastest growth in the 45-65 age group. Traditionally a 3-night hospital stay, joint replacement has benefitted from rapid recovery programs that have fostered earlier discharge to home. For properly-selected patients, same-day joint replacement has been a growing trend across the country.

Most same-day joint replacements have been performed in a hospital’s outpatient department. However, numerous factors have spurred the transition of these cases to ambulatory surgery centers (ASCs). Nationwide, there has been an explosion in ASCs in the past decade, both free-standing and hospital-affiliated. This growth has been fueled by the transition of other services to the outpatient setting such as cardiology, gastroenterology, ENT, and ophthalmology. Further growth has been driven by patients’ growing desire to recover in the comfort of home and to avoid an inpatient hospital stay during the COVID pandemic.

The transition of joint replacement surgery to the ASC has been equally driven by payment-related incentives. The Center for Medicare Services has recently approved both total knee and hip replacement for the ASC setting, recognizing abundant clinical data supporting its safety. Commercial insurance companies are also beginning to offer reimbursement incentives for surgeons to perform these cases in the ASC as a method of reducing healthcare costs. Finally, alternative payment models, such as bundled payments and direct employer contracting with self-insured companies, favor the cost savings that can be realized in an ASC compared to a hospital inpatient or outpatient setting. As these market forces continue to influence joint replacement care, it is projected that more than 50% of total joints will be performed in ASCs by 2026.

The higher complexity of these cases demands a much greater level of care coordination both by the ASC as well as the physician care team. Patient selection and education, home preparation, prehabilitation, regional anesthetic techniques, less invasive and customized surgical techniques, multimodal pain management and careful navigation of the postoperative care are all essential ingredients to the success of ASC joint replacement programs. Safely sending patients directly home just hours after surgery demands perfection and commitment. Experience matters for
good results.

Drs. Thomas King and Moby Parsons, and Kathleen Leavitt PA-C of the Knee, Hip and Shoulder Center in Portsmouth, NH have developed a rapid recovery, outpatient care pathway called AVATAR. An acronym that stands for Alignment of Vital Assets To Accelerate Recovery, this program represents the synthesis of many years of advancing joint replacement surgery and perioperative care. Rather than focusing on just the surgery itself, AVATAR recognizes the importance of coordinating and navigating all aspects of the process from preoperative through full recovery. AVATAR has led to less pain, faster recovery and better outcomes. When this can be combined with the cost savings of an ASC, both patients and payers achieve higher value in terms of the care.

Collectively, King and Parsons have performed over 2,000 outpatient knee, hip and shoulder replacements with 70-80% of patients now going home within hours of surgery. This includes over 300 cases performed at Stratham Ambulatory Surgery Center as a bundled payment program. With an intense focus on quality, the AVATAR ASC program boasts a 0% infection rate, 0% hospital readmission rate and a <1% reoperation for surgically related problems. These numbers are far better than national norms attesting to the success of this program.

As skyrocketing healthcare costs continue to drive value-based solutions, and as self-insured companies look for lower cost alternatives to fee-for-service medicine, the AVATAR bundled payment program can provide significant cost savings for joint replacement and other outpatient orthopedic procedures. For more information, contact

Dr. Thomas V. King (pictured, left) is a leading expert in hip and knee replacement and pioneer of the AVATAR same-day joint replacement surgery program. Dr. Moby Parsons (pictured, right) specializes in less invasive shoulder, hip and knee replacement and helped to develop surgical navigation technology that is now used worldwide.

All Stories