Sunday, July 31, 2016

Outpatient total shoulder arthroplasty

Outpatient total shoulder arthroplasty: a population-based study comparing adverse event and readmission rates to inpatient total shoulder arthroplasty.

These authors queried the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database to identify patients who underwent primary TSA between 2005 and 2014, dividing them into the 173 who had outpatient arthroplasty and the 7124 that had inpatient arthroplasty.

The 30-day adverse event rate in the outpatient and inpatient TSA cohorts was 2.31% and 7.89%, respectively. The 30-day readmission rate in the outpatient and inpatient TSA cohorts was 1.74% and 2.93%, respectively. In the multivariate logistic regression, the odds of an adverse event or readmission were not significantly different (odds ratios of 0.4 [P = .077] and  0.7 [P = .623], respectively).

Comment: The two groups are far from comparable: patients in the outpatient group were younger, more likely to be male and healthier and to have simpler pathology (as indicated by short operative time) as shown in the table below.

While the authors suggest that the average daily hospitalization cost of arthroplasty is $4000, we recognize that the costs are not evenly distributed: the preponderance of cost is experienced on the day of surgery, so that it is not the case that each day of shortening of the stay saves $4000.

We recognize that there may be financial and marketing incentives for surgeons to perform these surgeries in an outpatient center setting. However, such arrangements place new responsibilities on the surgical team to closely monitor the comfort and well-being of the discharged patient. In this study less than 3% of the shoulder patients had their procedures performed as outpatients, suggesting that at present this is not a widely accepted standard practice and that ambulatory shoulder arthroplasty is not currently an effective mode for reducing the annual expenditures for shoulder joint replacement.

In our practice, a two day post arthroplasty hospital stay enables multiple visits of the physical therapist to launch the early assisted motion program and multiple surgical team visits to assure the comfort and safety of the patient prior to discharge. With this approach 30 day readmissions are rare and patient satisfaction is high.