Safety and Cost Effectiveness of Outpatient Total Shoulder Arthroplasty: A Systematic Review
These authors conducted a systematic review of patient selection, perioperative protocols, complications, costs, patient satisfaction, and clinical outcomes of outpatient total shoulder TSA and compared these with inpatient total shoulder TSA.
Their review identified 25,808 and 231,408 patients undergoing outpatient and inpatient TSA, respectively.
Patient selection for outpatient TSA was based on patient age, medical comorbidities, social support, living proximity to location of surgery where emergency care is available.
Common criteria for outpatient arthroplasty included
age younger than 70 years
no evidence of preoperative anemia or previous venous thromboembolism
no chronic obstructive pulmonary disease; no uncontrolled sleep apnea
no cardiac comorbidities (no heart failure, no anticoagulation use and two or fewer cardiac stents).
no pacemaker or defibrillator
no opioid dependence
no hypertension or diabetes
no bleeding disorder, dialysis, cancer
no peripheral vascular disease
no depression
no chronic anemia
approval for outpatient surgery by anesthesia staff
adequate social support
close proximity of residence to the hospital or ASC
ASA Physical Status scores of 3 or less
Readmission rates were similar between inpatients and outpatients, with one study finding more readmissions after inpatient TSA.
Five studies found that patients having outpatient TSA were at a lower risk of overall complications,and
shoulder-related complications (eg, dislocation, manipulation under anesthesia, surgical site infection, capsulitis, and hematoma).
Three articles discussed reasons for outpatient readmissions; medical complications (n = 57, 67.0%), implant-related complications (n = 17, 20.0%), and uncontrolled pain (n = 11, 13.0%) were the most common.
Five studies found no statistical difference in ED visits between outpatient and inpatient TSA.
Ten studies, with 446 outpatient TSAs found that only six patients (1.3%) having outpatient arthroplasty required an unplanned overnight stay.
Reasons for failed outpatient surgery were surgery delays, patient convenience, hypoxia and not meeting postanesthesia care unit (PACU) discharge criteria.
Outpatient TSA demonstrated a charge reduction of $25,509 to $53,202 per patient. One study found that a bundled payment program in an ambulatory surgery center reduced total charges of care, mainly through reduced implant charges ($42,410 versus $44,530, P = 0.024).
Patient satisfaction after outpatient TSA was “good to excellent” in more than 95% of patients.
Comment: It is apparent that the successful implementation of an outpatient arthroplasty program requires dedication to a carefully delineated patient selection program, a well organized approach to preoperative education, anesthesia, postoperative pain management, and infrastructure to support patients that may have postoperative difficulties. It also requires thoughtful scheduling, in that a patient having early morning surgery is more likely to be ready for same day discharge than a person having arthroplasty in the late afternoon.
Performance of arthroplasty in an ambulatory surgery center may enable cost-saving negotiations, such as implant cost - the principal driver of arthroplasty expense.
Finally, there may be other selection bias effects of outpatient vs inpatient arthroplasty. It seems possible that patients having outpatient surgery would be more likely to have commercial insurance, to have higher household incomes, to have better family support, and to be better educated - each of which is likely to be associated with better outcomes. While these patient characteristics were not investigated in this study, it seems important that they be included in future studies.
If outpatient surgery enables lower implant costs and selects for socially advantaged patients who are likely to have better outcomes, the value (benefit/cost) will be appear to be greater for ambulatory surgery. These effects should be controlled for in comparative studies.
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