Optimizing Anesthetic Care for Pediatric Tonsillectomy and Adenoidectomy in Ambulatory Surgery Centers

Background:Ambulatory surgery or outpatient surgery is becoming increasingly common. In 2002, 63% of all operations performed in the United States were ambulatory procedures. Bariatric procedures performed in the United States have increased from 16,200 in 1992 to approximately 205,000 in 2007. In 2002, our center began offering laparoscopic Roux-en-Y gastric bypass (LRYGB) procedures on an outpatient basis for select candidates at an ambulatory surgery center (ASC). We subsequently added laparoscopic adjustable gastric band procedures (LAGB) in 2005.Methods:Between 2002 and 2008, 248 LRYGB and LAGB patients were carefully selected for ASC surgery by the bariatric surgeon and medical director. Extensive preoperative education was mandatory for all surgical candidates.Results:Since 2002, we have performed 248 bariatric cases at the ASC, including 38 LRYGB and 210 LAGB procedures. In this overall experience, 5 patients (2%) required readmission within 30 days of surgery, and 98.6% of LAGB patients were discharged the same day; 62% were discharged after a 4-hour to 6-hour stay in the ASC. All LRYGB patients remained in the ASC overnight and were discharge within 24 hours of their procedure. Weight loss results have been excellent.Conclusion:LAGB surgery can be safely performed in an ASC setting in most patients. LRYGB can be performed safely in the ASC setting with careful scrutiny and cautious selection of patient candidates.

See Article, p 699 GLINDA: Are you ready now? DOROTHY: Yes… GLINDA: Then close your eyes, and tap your heels together three times. And think to yourself -- "There's no place like home; there's no place like home; there's no place like home." DOROTHY: There's no place like home. There's no place like home. There's no place like home. There's no place like home. —The Wizard of Oz (1939) Noel Langley, Florence Ryerson, and Edgar Allen Woolf The concept of multimodal postoperative recovery programs—commonly referred to as enhanced recovery after surgery (ERAS) programs or "fast-track surgery"—was first proposed by Kehlet and Wilmore1 more than 20 years ago, when it was recognized that isolated, single clinical interventions were inadequate in addressing the problem of multifactorial perioperative complications and morbidity. Although simple in principle, collective experience and reported data during the interim 20 years have observed relatively slow progress in disseminating, implementing, and sustaining ERAS programs.2,3 This can likely be partly explained by the requirement for multidisciplinary collaboration, as well as cultural and organizational factors that frequently impede fundamental change in traditional patient care.2,3 Furthermore, the initial protocols for open colonic surgery included only a few essential principles of ERAS, whereas, the advent of more multifaceted and complicated ERAS programs and protocols have hampered implementation.2 From the contemporary perspective, the main issue still to resolve with ERAS programs is how to make further progress in achieving the ultimate goal of a risk-free surgical procedure.2 Thus future ERAS strategies should include a shift away from the conventional endpoints of early recovery and shortened length of stay to place more emphasis instead on mitigating postdischarge problems.2,4 However, at least in the United States, there are major health care policy changes that mandate continued attention on postoperative early recovery and reduced length of stay. No matter what the postoperative priorities, fundamentally transforming the traditional structures and processes of surgical and anesthetic care can indeed be challenging. Fortunately, there are innovators paving the way. In this issue of Anesthesia & Analgesia, Tokita et al5 provide a comprehensive description of a very innovative migration of complex cancer surgery from the hospital setting to an ambulatory extended recovery (AXR) setting of the Josie Robertson Surgery Center (JRSC) at Memorial Sloan Kettering Cancer Center (MSKCC). A key first question is "What is ambulatory extended recovery after surgery?" In 2003, the International Association for Ambulatory Surgery (IAAS) provided very pertinent, international consensus-based terminology (Figure 1).6 The IAAS has also made the following fundamental functional distinction:7Figure 1.: Basic terminology related to surgical encounter timeframes and synonyms.6 True ambulatory surgery is where patients are admitted, operated on, and discharged during the time frame of 1 working day (6–8 hours). There is no overnight facility stay. Ambulatory surgery with extended recovery is where patients are admitted, operated on, and stay for 1 night postoperatively with an overall stay up to 23 hours. To fully realize the potential expansion of ambulatory surgery, one must first understand the definition and current limitations of the different types of ambulatory surgery facilities. An ambulatory surgery center (ASC) is a freestanding facility that typically performs surgical procedures that do not require overnight stay. An ASC is not required to be associated with a hospital. An ambulatory surgery facility, which is not associated with a hospital, can perform surgical procedures stipulated on the current US Centers for Medicare & Medicaid Services (CMS) ASC covered procedures list. However, such an independent ASC cannot perform any procedures on the current Medicare inpatient-only (MIO) list (Figure 2). This significantly differs from a hospital outpatient department (HOPD), which is 100% owned by a hospital and is not limited in its procedural scope. Hospital-owned facilities can perform ambulatory surgery within the hospital, in a facility attached to the hospital, or in a facility physically separated from the hospital. In the United States, an HOPD is reimbursed at a markedly higher rate by CMS than an independent ASC. There are other significant differences between an independent ASC and an HOPD (Figure 2).8–10Figure 2.: Characteristics of an independent ASC versus a HOPD as defined by the US CMS.8–10 ASC indicates ambulatory surgery center; CMS, Centers for Medicare & Medicaid Services; HOPD, hospital outpatient department.Tokita et al5 accordingly note that organizationally, (a) the JRSC is part of the MSKCC and operates as a hospital-associated outpatient clinic; (b) the JRSC is attached to the Memorial Hospital ambulatory license; and (c) all JRSC staff are employed at MSKCC. These specific organizational aspects of the JRSC might make its AXR model neither feasible nor appropriate in a conventional ASC—particularly from a financial perspective. According to US CMS Rule 42 C.F.R. §412.3(e), a hospital admission is classified as inpatient if the surgical procedure is on the MIO list, or if the provider expects that the hospital stay will cross 2 midnights. If a surgical procedure on its MIO list is performed in an outpatient setting or with postoperative observation status (minimum of 8 hours, but <24 hours), CMS might refuse to reimburse for the procedure. If a surgery is not on its MIO list, CMS will only reimburse for postoperative inpatient status if clinical documentation can justify the need for a greater than 2 midnight stay.11,12 Importantly, a documented comprehensive preoperative patient assessment, which applies objective, well-defined clinical criteria for recommending postoperative inpatient versus outpatient status,13 can validly and compliantly be provided by a Perioperative Medicine program and clinic.14 The initial, major challenge at MSKCC was thus identifying the types of surgical procedures—with historical average inpatient hospital stays of 2–4 days—that with suitable patient selection and management, could be safely discharged home after a single overnight stay.5 While technically qualifying as ambulatory or outpatient procedures from a regulatory standpoint and payer perspective, Tokita et al5 distinguish these more complex, short-stay, AXR procedures from conventional outpatient procedures after which the patient recovers and is discharged home in a few hours. Here again, a Perioperative Medicine program and clinic can play a very important role in implementing patient selection criteria and undertaking needed medical optimization for an AXR procedure.15,16 The MSKCC leadership and other organizational stakeholders were guided by a set of principles and a series of related questions in developing the JRSC, which are not only illustrative but also vital for other entities pursuing any such pioneering health care delivery model:5 How can we become national leaders in delivering high-quality and cost-effective day and short-stay surgery? How can we maximally standardize processes and procedures? How do we continually assess progress to innovate and improve? How can we apply new technology to streamline processes and allow staff to focus on patients? What are the optimal roles for nurses and advanced practice providers within this short-stay environment? Most importantly, how can we ensure that the needs and experience of the patient and their loved ones are considered and prioritized in everything we do? With more extensive surgical procedures being performed in an ambulatory setting, it is necessary that patient safety is not jeopardized. The ERAS principles that allowed the migration of these surgical procedures to the outpatient setting must still be applied. This would reduce unplanned hospital transfers from the ambulatory facility, as well as mitigate emergency department visits and acute care hospital readmission after discharge. These adverse outcomes might negate the cost-effectiveness of moving the surgical procedures to the outpatient setting. Future studies should investigate approaches to identify and manage postdischarge complications. This could be achieved with real-time electronic symptom monitoring systems similar to the one used by Tokita et al.5 In addition, such electronic systems can provide patient self-management advice that could reduce unnecessary emergency department visits. These systems could also directly assess patient-reported outcomes. Such monitoring would also allow identify the timeline of complications and classify them as medical versus surgical, and determine approaches toward preventing them. Medical complications can be addressed through modifying patient selection criteria and perioperative management. In contrast, surgical complications can be addressed through reassessment of perioperative care, as well as surgical technique and expertise. In summary, there has been a continued, and likely future sustained expansion of the number of ASCs and the number of procedures performed in ASCs, particularly in the United States but also worldwide.17–19 As insightfully observed by Philip,10 such outpatient surgery has been a success in the United States because of 2 important reasons: (1) a focus on efficiency, quality, and cost of care and (2) a focus on the patient and the role of humanism in medicine. The pioneering work of Simon and colleagues in creating the JRSC at MSKCC exemplifies these 2 fundamental tenets of health care value and humanism.5 Nevertheless, in order for AXR to achieve its ultimate yet still potential positive health care impact, it must be financially sustainable in an ASC setting. At least in the United States, this will require major, progressive changes to current CMS regulations and reimbursement. DISCLOSURES Name: Thomas R. Vetter, MD, MPH. Contribution: This author helped write and revise the manuscript. Name: Girish P. Joshi, MBBS, MD, FFARCSI. Contribution: This author helped write and revise the manuscript. This manuscript was handled by: Jean-Francois Pittet, MD.

Introduction Current literature is limited in assessing nationwide trends of penile prosthesis (PP) placement in the United States largely due to a lack of data on outpatient PP placement. Particularly no nationwide comparison of ambulatory surgery center (ASC) versus inpatient hospital (IH) PP placement has been published. Objective Our objective is to determine the trends of PP placement in ASCs vs IHs utilizing representative nationwide data. Additionally, we examined patient demographics that are associated with the setting for PP placement. Methods Inpatient and outpatient encounters for PP placement between 2016 and 2019 were analyzed using data from the Nationwide Inpatient Sample (NIS) and the Nationwide Ambulatory Surgery Sample (NASS) from the Healthcare Cost and Utilization Project (HCUP). These are the largest publicly available inpatient and ambulatory surgery databases available in the United States. PP operations were identified by CPT and ICD-10-PCS codes. Subsequent analysis was performed using the established weighting provided by the HCUP, which utilizes stratified cluster sampling to create national estimates. Comparisons of demographics were performed using t-tests and chi-square tests with a p-value for significance &amp;lt;0.05. Results Over the study period, there were 67,722 PP placements in the United States. The percentage placed in ASCs was 93.1%. In 2016, 16,290 PP placements occurred, of which 92.3% were placed in ASCs. Comparatively in 2019, there was a 7.3% increase (17,473) in the number of PP placements, with 94.5% placed in ASCs (p&amp;lt;0.01). Over the study period, 33,008 PP placements were performed in the South (93.8% ASCs), 12,481 in the Midwest (94.6% ASCs), 12,192 in the Northeast (92.4% ASCs), and 10,040 in the West (90.1% ASCs, p&amp;lt;0.01). The average age of patients receiving a PP placement was 64.4 in ASCs compared with 62.5 in IHs (p&amp;lt;0.01). The average cost associated with PP placement in ASCs was $25,935, about half the cost of inpatient settings, which averaged $51,594 (p&amp;lt;0.01). Of all PP implants, the primary payer was medicare for 57.1% (38,660; 93.1% ASCs), medicaid for 4.4% (2980; 86.6% ASCs), private for 33.6% (22,778; 94.3% ASCs), and self-pay for 1.1% (768; 90.9% ASCs, p &amp;lt;0.01). Conclusions Our results suggest that the number of PP placements is consistently rising each year, with an increasing majority of PP placements performed in ASCs. The procedure costs roughly half on average when performed in ASCs compared to IHs. Further investigation is needed to compare complication rates and outcomes of PP placements in ASC versus IH. Disclosure No

Mixed potential impact on endoscopy centers of medicare bill

Pioneering a Value-Based Purchasing Initiative for Ambulatory Surgery Centers in TRICARE West.

To investigate the epidemiological impact of an ambulatory cataract surgery center providing a fast-track procedure without anesthetic evaluation on the access to cataract healthcare. French nationwide study. Retrospective cross-sectional study. The study included individuals undergoing cataract surgery from the French national administrative database of medical information. Data analyses focused on patients living in the Cher and neighboring areas. Epidemiological indicators of patient flow and healthcare efficiency were calculated. A medicoeconomic analysis was performed. Between 2012 and 2018, activity increased by +50.2% (3665 to 5506) interventions in the Cher area compared with a national increase of +22.7% (720 351/884 254), while maintaining a constant ophthalmologist workforce. The leakage ratio decreased by 5.9 points (26.3% to 20.4%), whereas the attractiveness and self-sufficiency ratios increased by 2.3 (8.6% to 10.9%) and 8.6 (80.6% to 89.2%) points, respectively. The age- and sex-standardized rate of healthcare utilization for cataract surgery increased by 4.3 points (11.6 to 15.9 cataract surgeries per 1000 inhabitants), making the Cher the second best French area in 2018 for the rate of cataract surgery despite ranking 96th of 109 French areas for ophthalmologist density. The cost of the cataract removal procedure was 523.99€ (666.22€ in the conventional operating room). An ambulatory cataract surgery center with a fast-track procedure could represent a solution in medical deserts to improve cataract healthcare without supplementary funding. Nonetheless, consulting activity should be optimized to detect eye disorders and schedule interventions.

Category: Ankle; Trauma Introduction/Purpose: Ankle fracture open reduction and internal fixation (ORIF) is one of the most commonly performed orthopaedic surgeries, which can be performed at a variety of surgical locations. However, there is very little data exploring the cost and efficiency of ankle fracture ORIF in different operative settings. Time-Driven Activity Based Costing (TDABC) is a novel accounting method used to accurately assign costs for various procedures by creating a process map of all personnel interactions as a patient moves through a care event. Further, it has been shown to more accurately allocate costs, as compared to traditional accounting systems. Our purpose is to evaluate cost and efficiency differences in ankle fracture ORIF at an outpatient ambulatory surgery center (ASC) versus a hospital setting. Methods: A prospective cohort study was performed at a single academic medical center involving four orthopaedic surgeons. Patients were enrolled with uni-, bi-, or tri-malleolar displaced ankle fractures undergoing ORIF. According to TD-ABC methodology, a process map was created for each peri-operative platform and hand-timed data was collected at each location (ASC=5, hospital=5) by a single observer. In addition, retrospective cost data was obtained from 181 surgical cases using our institution's existing cost accounting system (ASC=34, hospital=147). Average event times and care costs were calculated for both locations, and a process map outlining the steps of care was created for each surgical site, according to TDABC methodology. Data were analyzed to investigate the effects of surgical site on labor cost, efficiency, and provider time. Results: Overall, total direct cost was similar between locations (ASC=$10,837.43, hospital=$9,377.80; p=.114), although there were significantly higher direct costs in the hospital: perioperative/anesthesia (ASC=$2,532.61, hospital=$4,594.20; p&lt;.001), pharmacy (ASC=$112.18, hospital=$349.74; p&lt;.001), radiology (ASC=$17.67, hospital=$227.98; p&lt;.001), and therapy (ASC=$28.23, hospital=$130.91; p&lt;.001). However, medical supply costs, including implant costs, were significantly higher at the ASC (ASC=$7,835.14, hospital=$2,459.60; p&lt;.001). Preoperatively, nurse assessment of the patient was significantly quicker in the hospital (ASC=14.65 min, hospital=5.10 min; p=.030), while patient transport to the operating room was significantly quicker in the ASC (ASC=1.20 min, hospital=2.60 min; p=.014). Case duration was significantly longer in the ASC (ASC=138.60 min, hospital=56.60 min; p=.005), which may have been influenced by case complexity, as there were more tri-malleolar fractures (n=2) and concomitate ankle arthroscopies (n=3) in that cohort. Conclusion: Overall, direct costs appear to be lower at the ASC than the main hospital, although efficiency of care delivery seems similar. Generally, there were small differences in the care continuum between the main hospital and ASC, though areas where improvement could be obtained include preoperative nurse assessment of the patient and efficacy of regional nerve block administration. Going forward, larger studies will be needed to further investigate these results.

131. Primary single-level lumbar discectomy/decompression at a free-standing ambulatory surgery center (ASC) vs a hospital-owned outpatient facility (HOPD): an analysis of 90-day outcomes and costs

63 INCREASING RATE OF FLUOROQUINOLONE RESISTANT ESCHERICHIA COLI AND INCIDENCE OF INFECTIOUS COMPLICATIONS FOLLOWING TRUS GUIDED PROSTATE NEEDLE BIOPSY IN CALGARY, ALBERTA, CANADA

Assessing Medicaid Accessibility to Total Knee Arthroplasty: Comparison of Ambulatory Surgery Centers and Hospitals.

General hospitals are consistently under pressure to control cost and improve quality. In addition to mounting payers' demands, hospitals operate under evolving market conditions that might threaten their survival. While hospitals traditionally were concerned mainly with competition from other hospitals, today's reimbursement schemes and entrepreneurial activities encouraged the proliferation of outpatient facilities such as ambulatory surgery centers (ASCs) that can jeopardize hospitals' survival. The purpose of this article was to examine the relationship between ASCs and general hospitals. More specifically, we apply the niche overlap theory to study the impact that competition between ASCs and general hospitals has on the survival chances of both of these organizational populations. Our analysis examined interpopulation competition in models of organizational mortality and market demand. We utilized Cox proportional hazard models to evaluate the impact of competition from each on ASC and hospital exit while controlling for market factors. We relied on two data sets collected and developed by Florida's Agency for Health Care Administration: outpatient facility licensure data and inpatient and outpatient surgical procedure data. Although ASCs do tend to exit markets in which there are high levels of ASC competition, we found no evidence to suggest that ASC exit rates are affected by hospital density. On the other hand, hospitals not only tend to exit markets with high levels of hospital competition but also experience high exit rates in markets with high ASC density. The implications from our study differ for ASCs and hospitals. When making decisions about market entry, ASCs should choose their markets according to the following: demand for outpatient surgery, number of physicians who would practice in the surgery center, and the number of surgery centers that already exist in the market. Hospitals, on the other hand, should account for competition from ASCs while making market-entry decisions and while developing their strategic plans.

Introduction: In January 2020, Medicare began reimbursing for percutaneous coronary intervention (PCI) performed in ambulatory surgery centers (ASCs), but little is known about characteristics and outcomes of patients who have undergone ASC PCI previously. Methods: Using commercial insurance claims from the MarketScan® Databases, we characterized patients 18 years or older who underwent hospital outpatient department (HOPD) or ASC PCI for stable ischemic heart disease between April 1, 2007, and December 1, 2016. We used propensity score matching of HOPD and ASC PCI cohorts to measure the association between treatment setting and 30-day outcomes (myocardial infarction, bleeding complications, and all-cause admission). Results: The unmatched sample consisted of 95,492 HOPD and 849 ASC PCI patients. Patients were more likely to undergo ASC PCI if they were younger than 65 (OR 1.72, 95% CI 1.43-2.06), lived in the southern U.S., or were covered by managed (OR 2.31, 95% CI 1.73-3.08) or consumer-driven (OR 2.57, 95% CI 1.73-3.82) compared to comprehensive health plans. ASC PCI was less likely in patients with a history of stroke (OR 0.45, 95% CI 0.28-0.72). Intravascular imaging and physiology testing were more frequently performed in HOPD than in ASC PCI (18.3% vs. 12.5%, respectively; p &lt; 0.001). After propensity-score matching, ASC PCI was associated with increased odds of bleeding complications (OR 2.43, 95% CI 1.22-4.84, p = 0.011). Differences in other outcomes were not statistically significant. Conclusions: Patients undergoing outpatient elective PCI in ASCs were younger and more likely to live in the southern U.S or have managed or consumer-driven health insurance plans. Intravascular imaging and physiology testing were performed more frequently in HOPD than in ASC PCI. PCI in the ASC setting was also associated with an increased risk of bleeding complications. Further study of this population is warranted as ASC PCI volume increases under Medicare.

Objectives: Anterior cruciate ligament reconstruction (ACLR) is one of the most performed orthopedic procedures in the United States and the volume and cost are increasing annually. Patients are increasingly expected to share a larger economic burden with out-of-pocket expenditures. Recently, there has been a shift to perform more ACLR surgeries outside of the hospital setting to reduce costs. The purpose of this project is to understand the differences in costs between ACLR performed in ambulatory surgery center (ASC) versus outpatient hospital settings and if or how this affects the patient’s out-of-pocket expenditure. Methods: We identified patients who had undergone outpatient arthroscopic ACLR in the United States (U.S.) using the IBM MarketScan Commercial Claims and Encounters Database. The database was chosen for its large, national sample of privately insured patients. Patients who had Current Procedural Terminology (CPT) code 29888 between April 1, 2013 and June 30, 2017 were included. Revision ACL procedures and procedures with a concomitant microfracture, medial collateral ligament, lateral collateral ligament, or posterior cruciate ligament repair or reconstruction (CPT: 29879, 27405, 27409, 27427, 29889) were excluded. Day-of-surgery expenditure was identified by summing all claims billed with an “immediate-procedure-related code” in a 3-day window surrounding the date of the procedure (Procedure Date ± 1 Day). The day-of-surgery expenditure was broken down into implant, anesthesia services, regional anesthesia, operating room facility, surgical team, and other expenditures. Regional anesthesia is not included in anesthesia services expenditure. Median and interquartile range were calculated for each variable. The breakdown of day-of-surgery expenditure and patient out-of-pocket expenditure between the outpatient hospital and ASC settings were compared using two-tailed Mann Whitney U Tests. Spearman Rank Order Correlation was done for all variables to test for association between expenditure and year to determine trends over time. All values were inflation adjusted to 2017 dollars. Results: A total of 34,862 patients were identified. Our results indicated that ACLR performed in the outpatient hospital setting result in 60% greater day-of-surgery expenditure (p &lt; 0.001) than in the ASC setting. In the outpatient hospital setting, operating room facility cost was 36% greater (p &lt;0.001), anesthesia services was 7.1% greater (p&lt;0.001), implant was 28% greater (p&lt;0.001), but regional anesthesia was 22% lower (p&lt;0.001). Additionally, for ACLRs performed in the outpatient hospital setting, Spearman coefficients demonstrated that expenditure for anesthesia services decreased (rho = -0.037, p &lt; 0.001) and operating room facility cost increased (rho = 0.058, p &lt; 0.001) over our study period. For ACLRs performed in the ASC setting, expenditure for regional anesthesia decreased (rho = -0.039, p &lt; 0.001). Surgical team reimbursement decreased over time for ACLRs performed in both the ASC (rho = -0.156, p &lt; 0.001) and outpatient hospital (rho = -0.11, p &lt; 0.001) settings. Lastly, total patient out-of-pocket expenditure for ACLRs performed in the outpatient hospital setting vs. ASC setting was very similar though statistically different (p = 0.02, &lt;$10 difference). Conclusions: ACLR performed in an ASC setting results in significant cost savings for payers with no change in surgeon reimbursement. Most of the cost savings came from operating room facility expenditure. For patients, there is almost no financial difference regarding where the ACLR was performed, with the difference in patient out-of-pocket expenditure being less than $10. For the surgeon, surgical team reimbursements are essentially neutral between the ASC and outpatient hospital settings. However, the overall trend in surgical team reimbursement is downwards in both the ASC and outpatient hospital settings. For the two biggest stakeholders in the surgery (surgeon and patient), there are no financial incentives to do an ACLR at an outpatient hospital over an ASC. For a healthcare system, especially under a population health perspective, the incentive to perform ACLRs at an ASC is significant. The cost savings come from every breakdown category, with implant and operating room facility costs being significantly decreased in the ASC setting. Decreased implant costs were likely due to preferred vendor contracts for ASCs. The cost savings achieved per ACLR in an ASC vs. an outpatient hospital equals almost $6000. With nearly 100,000 ACLRs performed per year, the U.S. healthcare system could save a projected $600 million per year on ACLRs alone when the surgery is performed in an ASC. Thus, our study shows that there is a clear financial advantage to the healthcare system for ACLRs being done at ASCs, although the patient does not realize these cost savings. [Figure: see text][Table: see text][Table: see text][Table: see text]

Outpatient Total Knee Arthroplasty From a Stand-Alone Surgery Center: Safe as the Hospital?

Total joint arthroplasty is shifting from hospitals to ambulatory surgery centers (ASCs) and hospital outpatient departments (HOPDs). A Michigan Arthroplasty Registry Quality Collaborative Initiative quality improvement project examined readmissions, emergency room (ER) visits, periprosthetic joint infection (PJI), fracture, and dislocation after primary total hip arthroplasty (THA) or total knee arthroplasty (TKA) across sites. Primary TJAs between July 1, 2021, and June 30, 2022 (N= 41,696: 3910 ASC, 1,834 HOPD, and 35,952 hospital) were reviewed. Of 17,100 THAs, 9.5% (1,631) were at ASCs, 4.7% (798) at HOPDs, and 85.8% (14,671) at hospitals. Of 24,596 TKAs, 9.3% (2,279) were at ASC, 4.2% (1,036) at HOPDs, and 86.5% (21,281) at hospitals. Hospitals treated more elderly, women, non-White, obese, diabetics, smokers, and governmental insurance. For THAs, ASCs had the lowest 30-day (ASC 1%, HOPD 1.8%, hospital 3.4%, P < .001) and 90-day (ASC 1.7%, HOPD 3.4%, hospital 5.5%, P < .001) readmissions, 30-day ER visits (ASC 1.8%, HOPD 3.5%, hospital 5.3%, P < .001), and fractures (ASC 0.4%, HOPD 0.6%, hospital 1.2%, P < .001). Similar trends were observed for TKAs: 30-day readmissions (ASC 1.3%, HOPD 1.4%, hospital 3.1%, P < .001), 90-day readmissions (ASC 2.2%, HOPD 2.3%, hospital 5.2%, P < .001), and 30-day ER visits (ASC 3%, HOPD 6.5%, hospital 6.4%, P < .001). PJI (THA: P= .1, TKA: P= .6) and dislocation rates (P= .5) were similar across sites. Patients receiving primary total joint arthroplasty at an ASC had the least postoperative hospital-based care despite similar rates of PJI and dislocation.