The value of outpatient shoulder arthroplasty and selection bias

 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.

Follow on twitter: https://twitter.com/shoulderarth

Follow on facebook: https://www.facebook.com/frederick.matsen

Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

How you can support research in shoulder surgery Click on this link.

Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link)

Shoulder arthritis - x-ray appearance (see this link)

The smooth and move for irreparable cuff tears (see this link)

The total shoulder arthroplasty (see this link).

The ream and run technique is shown in this link.

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

Shoulder rehabilitation exercises (see this link).

This is a non-commercial site, the purpose of which is education, consistent with "Fair Use" as defined in Title 17 of the U.S. Code.          

Note that author has no financial relationships with any orthopaedic companies.

Outpatient shoulder arthroplasty - should there be an age cut-off?

Is outpatient shoulder arthroplasty safe in patients aged >65 years? A comparison of readmissions and complications in inpatient and outpatient settings

This study sought to compare surgical complication rates and 90-day readmission rates between inpatient and outpatient TSA performed in adults aged ≥ 65 years by an individual surgeon.

Patients were preselected for outpatient or inpatient surgery based on lack of significant cardiopulmonary comorbidities (e.g. presence of cardiac stents, congestive heart failure, and severe chronic obstructive pulmonary disease) and patient preference.

Outpatient TSA was defined as those procedures in which patients were discharged home from

the postanesthesia care unit (PACU),

A total of 145 shoulders (138 patients; 95 male, 43 female) were included in the analysis, of which 98 received inpatient TSA and 47 received outpatient TSA. Average age was 75.5 for inpatient TSA and 70.5 for outpatient TSA. 

Patient age, ASA score ≥3, and reverse TSA were significantly positively correlated with receiving inpatient surgery. 

Each 1-year increase in age increased the predicted odds of having a surgical complication by 14%, irrespective of surgical setting. 

In the inpatient group, there were a total of 16 complications (complication rate 16.3%). 4 major surgical complications required reoperation (4.1%): implant instability in 3 cases (all reverse TSA) and 1 patient with anatomic TSA sustained a greater tuberosity fracture after a seizure. 7 minor complications consisted of 1 heterotopic ossification, 2 isolated acromial stress reactions, 1 ruptured distal biceps tendon, and 1 acromial stress reaction with concomitant proximal biceps tendon rupture (long head). The 2 minor medical complications were hyponatremia secondary to acute kidney injury and anemia requiring transfusion. There were 5 intraoperative complications, consisting of 1 instance of skin shearing while positioning the arm and 4 intraoperative fractures.

In the outpatient group there were 9 complications (19.1%).  3 major complications required reoperation within 1 year (6.4%). Two of the 3 major complications were rotator cuff dysfunction after anatomic shoulder arthroplasty. The third major complication was instability after reverse TSA. There were 3 minor complications, all surgical, consisting of 3 acromial stress reactions. There was 1 intraoperative fracture sustained by a patient with osteogenesis imperfecta.

The most common causes of presentation to the ED within 90 days were medical complaints including fall (7), chest pain (2), urinary tract infection (2), syncope (2), bleeding (2), and angioedema (2). 

The causes for readmission included revision surgery (5), cardiovascular workup (3), urinary tract infection (3), acute kidney injury (2), pneumonia (1), extremity edema (1), gastrointestinal workup (1), and fall (1).

Comment: This surgeon offered outpatient arthroplasty to patients without clinically significant cardiovascular or pulmonary conditions and who desired to have outpatient surgery. Patients selected for inpatient surgery were older and had worse ASA scores. 

The incidences of surgical and medical complications are shown below. In spite of their worse ASA scores, the rate of medical complications for inpatients was not substantially different from that for outpatients. The big difference was in the rate of ED visits and readmissions. These differences were not caused by the inpatient/outpatient decision, but rather are a reflection of the greater fragility of those selected for inpatient surgery.

These results suggest that in this surgeon's practice, outpatient surgery is not a major risk factor for medical or surgical complications. Rather patients selected by this surgeon for inpatient surgery are at higher risk for postoperative ED visits and readmission

Each increase in age by 1 year increased the odds of postoperative surgical complications by 14%; this was true for both inpatient and outpatient surgery. This finding does not support the application of an age cut-off but rather using other criteria as discussed in this related post, "Is outpatient arthroplasty a good idea?"

Follow on twitter: https://twitter.com/shoulderarth

Follow on facebook: https://www.facebook.com/frederick.matsen

Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

How you can support research in shoulder surgery Click on this link.

Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link)

The smooth and move for irreparable cuff tears (see this link)

The total shoulder arthroplasty (see this link).

The ream and run technique is shown in this link.

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

Shoulder rehabilitation exercises (see this link).

This is a non-commercial site, the purpose of which is education, consistent with "Fair Use" as defined in Title 17 of the U.S. Code.          

Note that author has no financial relationships with any orthopaedic companies.

Outpatient shoulder arthroplasty - when is it a good idea?

Appropriate Patient Selection for Outpatient Shoulder Arthroplasty: A Risk Prediction Tool

These authors sought to develop a predictive model for patient discharge by postoperative day 0 or 1.

They used a multi-center cohort of 5,410 shoulder arthroplasties (2,805 anatomics, 2,605 reverses) from two geographically diverse, high-volume health systems.

2,238 (41.4%) patients were discharged at least by postoperative day 1, with no difference in rates of 90-day readmission (3.5% vs 3.3%) between short and extended length of stay (discharge after postoperative day 1).  True same-day discharge occurred in 3.9% of cases. Nine percent overall were discharged to a skilled nursing or rehab facility (anatomic: 5.9%, reverse: 12.3%, p < 0.001).

A multivariable logistic regression model demonstrated high accuracy (AUC: 0.762) for discharge by postoperative day 1, and was composed of 13 variables: surgery duration, age, gender, electrolyte disorder, marital status, ASA,  paralysis, diabetes, neurologic disease, peripheral vascular disease, pulmonary circulation disease, cardiac arrhythmia, and coagulation deficiency. The relative importance of each of these factors is shown below.

The predictive model was incorporated into an online tool  (see this link).

The two figures below show the predictions for two hypothetical patients who are identical except for one having a spouse/partner (blue) and the other having no partner or spouse (black), the latter have a 3X greater likelihood of discharge to SNF/Rehab.

Comment: While this study sought to determine preoperative predictors of length of stay >1 postoperative day, the strongest predictor was the duration of surgery - a value not known prior to admission. The model has yet to be validated as a predictor for same day discharge after arthroplasty.

In our practice the most important elements in planning same day discharge after arthroplasty are (1) a patient who is sufficiently healthy, robust and informed to leave the hospital on the day of surgery, 2) a support person who will be with the patient at discharge and for a few post discharge days, (3) comprehensive preoperative discussion with the patient and their support person to set expectations,  (4)  a robust plan for pain management, and (5) explicit contact information for a member of the surgical team who can be contacted in the event of questions or problems.

Follow on twitter: https://twitter.com/shoulderarth

Follow on facebook: https://www.facebook.com/frederick.matsen

Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

How you can support research in shoulder surgery Click on this link.

Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link)

The smooth and move for irreparable cuff tears (see this link)

The total shoulder arthroplasty (see this link).

The ream and run technique is shown in this link.

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

Shoulder rehabilitation exercises (see this link).

This is a non-commercial site, the purpose of which is education, consistent with "Fair Use" as defined in Title 17 of the U.S. Code.          

Note that author has no financial relationships with any orthopaedic companies.