Monday, September 12, 2016

Outpatient total shoulder joint replacement surgery - does it save money, is it safe? A repost

Outpatient total shoulder arthroplasty in an ambulatory surgery center is a safe alternative to inpatient total shoulder arthroplasty in a hospital: a matched cohort study.

These authors compared 30 patients having outpatient TSA at a freestanding ambulatory surgery center (ASC) with an age- and comorbidities-matched cohort of 30 patients with traditional inpatient TSA by the same surgeon.

These authors endeavored to optimize the safety of ambulatory surgery.  Eligibility was determined after both the surgeon and a staff anesthesiologist reviewed each patient’s health status, medical history, and medications.

They found no significant differences were found between the ASC and hospital cohorts regarding average age, preoperative American Society of Anesthesiologists score, operative indications, or body mass index. No patient required reoperation. There were no hospital admissions from the ASC cohort and no readmissions from the hospital cohort. 

Complications in the ASC cohort were arthrofibrosis in 2 patients and mild asymptomatic anterior subluxation in 1 patient; the only major complication was in an outpatient who fell 11 weeks after surgery and disrupted his subscapularis repair. Three minor complications in the hospital cohort were mild asymptomatic anterior subluxation, blood transfusion, and superficial venous thrombosis. 

Comment: This study suggests that outpatient total shoulder arthroplasty can be safe in carefully selected patients. Such a practice requires not only careful screening and consenting, but also immediate availability of postoperative support in the event of difficulties in pain management, bleeding, and medical issues.

It is of interest that while 30 of the inpatient cases were discharged on post operative day 1, 3 additional patients required an extra day of hospitalization. The reasons for the additional hospital day were pain control in 2 patients and dizziness with subsequent difficulty in mobilization for the third. One might wonder how these issues might have been managed had the occurred among those having outpatient surgery.

Because few of our patients live 'next door', our practice is to plan on a two-day hospital stay after shoulder arthroplasty during which time we initiate early range of motion exercises to minimize the risk of stiffness (as occurred in 2 of the 30 ASC cases) and to optimize pain and medical management.

As emphasized by the authors, outpatient arthroplasty is not appropriate for every patient and requires   a 'safety net' to catch any unexpected medical and surgical problems.

While the drive for outpatient surgery is apparently reduction in cost, the authors did not report the total cost savings of the outpatient cases in comparison to the inpatient cases.

Dr Seth Leopold, editor of CORR, has pointed out that studies of this size cannot fully evaluate the 'safety' of a procedure. Here's an informative editorial that he wrote (see this link). He asks a very important question: "What should it take for us to conclude that something is "safe"? I would assert that most orthopaedic studies are powered to efficacy, not to safety. Most complications that we care about are uncommon -- in the ballpark of 1-3%, perhaps less. With only 30 patients, one is quite likely not even to see them in such a study. So how can one conclude that this intervention is "safe"? It seems one can conclude it is "feasible", and if one likes the effects of it (eg, if patients are happy with it, or if they get somehow achieve better shoulder scores with one approach than another) then perhaps one can conclude it is "effective". But safety would take a good deal more patients to establish."

Thanks, Dr. Leopold.