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.

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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.

The safety of outpatient shoulder arthroplasty

The Feasibility of Outpatient Shoulder Arthroplasty: Risk Stratification and Predictive Probability Modeling 

These authors sought to identify risk factors for adverse events (AEs) following shoulder arthroplasty and to generate predictive models to improve patient selection using a retrospective review of a single institution shoulder arthroplasty registry as well as the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, including subjects undergoing hemiarthroplasty, total shoulder arthroplasty (TSA), and reverse TSA. Predicted probability of suitability for same-day discharge was calculated from multivariable logistic models for different patient subgroups based on age, comorbidities, and Charlson/Deyo Index scores. 

A total of 2314 shoulders (2079 subjects) in the institutional registry met inclusion criteria. 17% had adverse events. The most common were transfusion, bloodloss anemia, hypotension/shock, syncope,  and pulmonary problems

Factors associated with suitability for discharge included younger age, higher body mass index (BMI), male sex, and prior steroid injection.

Factors associated with adverse events included preoperative narcotic use, comorbidities (heart disease and anemia/other blood disease), and Charlson/Deyo Index score of 2.

Compared with TSA, reverse TSA was associated with less suitability for discharge.

15,254 patients were identified from the ACS-NSQIP database. 

Factors associated with unsuitability for discharge were female sex, BMI less than 35 kg/m², American Society of Anesthesiologists class III/IV, preoperative anemia, functional dependence, low preoperative albumin, and hemiarthroplasty.

The lowest risk subgroup included males 55 to 59 years old with no comorbidities nor history of narcotic use. Transfusion was the primary driver of adverse events.

The authors concluded that the majority of patients undergoing shoulder arthroplasty could safely be managed on an outpatient basis. In their institutional database, younger male patients with higher BMI were particularly likely to avoid adverse events, whereas those with certain comorbidities (anemia/blood disorder, heart disease) or history of narcotic use were somewhat more likely to have AEs. The authors found similar results on the national level, with female sex, lower BMI, significant comorbidities, and low preoperative albumin and hematocrit levels being risk factors for AEs. 

Comment: These authors have investigated patient characteristics related to adverse events after shoulder arthroplasty. While this information is helpful, avoiding these risk factors is only one component of the safety of outpatient joint replacement. Some important risk factors not mentioned are (a) history of prior problems with surgery or anesthesia and (b) history of urinary retention.

Other essential elements of successful outpatient arthroplasty include:

(1) Assurance that the patient is emotionally and intellectually "on board" with the plan for same day discharge and their responsibility for self-care and monitoring.

(2) Preoperative identification of family member or close friend who will be with patient during the first 24 hours after surgery and establishment of secure communication pathway between the surgical team and the support person.

(3) Confirmation with anesthesiologist of the plan for outpatient surgery

(4) Scheduling of case for the morning

(5) Preoperative education in wound management, pain management, physical therapy

(6) Call from surgical team to patient the night before and the evening of surgery

(7) Two hour preoperative hydration and calorie boost using clear energy shake

(8) Preoperative analgesic meds (such as Tylenol, Celebrex, Lyrica)

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

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Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages  arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Reverse total shoulder - older female patients with diabetes and obesity have more complications.

Outpatient vs. inpatient reverse total shoulder arthroplasty: outcomes and complications

These authors evaluated all patients who underwent outpatient RTSA performed by a single surgeon between 2015 and 2017. Demographic information and clinical outcome scores, as well as data on complications, readmission, and revision surgery were compared between the groups of patients having outpatient and inpatient reverse total shoulder arthroplasty. 

The demographics and comorbidities were substantially different between the two groups

 The rates and types of complications were also different between the two groups.

However the changes in clinical outcome scores were not significantly different between the two groups.

Comment: These authors found that RTSA performed in an outpatient setting is a safe and reliable procedure that provides significant improvements in clinical outcome scores. The observed reduction in  complications compared with inpatient RTSA  is probably attributable to differences in patient comorbidities.

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To see a YouTube of our technique for a reverse total shoulder arthroplasty, click on this link.

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How you can support progress in shoulder surgery

You may be interested in some of our most visited web pages  arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Outpatient rotator cuff repair - avoiding avoidable unplanned visits

Unplanned emergency department or urgent care visits after outpatient rotator cuff repair: potential for avoidance

These authors queried the records for 1306 outpatient rotator cuff repairs (RCR) in a closed health care system and all unplanned emergency department and urgent care visits within 7 days of procedures. The results for RCR were compared with other typical outpatient orthopedic procedures (knee arthroscopy, carpal tunnel release, and anterior cruciate ligament reconstruction). 

Avoidable diagnoses (ADs) for the unplanned visits were defined in advance as visits for (1) constipation, (2) nausea or vomiting, (3) pain, and (4) urinary retention.

 90 patients had unplanned return visits (6.9%), with 34 for avoidable diagnoses (2.6%). Pain was the most common avoidable diagnosis. However, when RCR was compared with other case types, unplanned visits for urinary retention were significantly more common.

The 1306 RCRs led to a greater proportion of unplanned visits than the combined 5825 other types of procedures studied.

In an attempt to decrease the number of ADs, this medical system has begun to implement a comprehensive perioperative care package including 

(1) counseling on pain management, constipation prevention, and return precautions

(2) prescriptions for postoperative pain to be filled the day before surgery

(3) a single 375-mL glass of a high-carbohydrate clear liquid up to 2 hours before surgery 

(4) multimodal analgesia with acetaminophen, gabapentin, and a nonsteroidal antiinflammatory drug started preoperatively

(5) fluid restriction to less than 500 mL during surgery

The effectiveness of these steps in reducing unplanned return visits is yet to be determined.

Comment: The quality of the outpatient surgery patient experience requires careful patient selection, detailed preoperative education and planning, and a readily available system for responding to patient concerns and medical issues such as those identified here.  

The reasons for the relative increase in urinary retention for patients having RCR in comparison to other procedures may be related to an increased use of pain medication by these patients or because RCR patients may be older and male (with risk of prostate issues). Extra preoperative attention may be necessary to avoid unplanned visits for this population.

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Use the "Search" box to the right to find other topics of interest to you.

How you can support progress in shoulder surgery

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Outpatient shoulder arthroplasty - surgeons' concerns about reimbursement.

Surgeons’ experience and perceived barriers with outpatient shoulder arthroplasty

These authors note that outpatient total shoulder arthroplasty (TSA) has been proposed as an alternative to the inpatient setting. They evaluated the expert shoulder surgeon’s experience with and perceived barriers to outpatient TSA.

They used a secure web application to perform an online survey of 484 active American Shoulder and Elbow Surgeons members. The survey assessed surgeon practice demographics, experience with TSA/outpatient TSA, and perceived barriers to successful outpatient TSA.

Of the 179 (37.0%) complete responses received, 20.7% perform outpatient TSA; of those, 78.4% reported an “excellent” experience. Outpatient surgeons were more likely to reside in the southern United States (P = .05) and performed a higher volume of TSAs annually (P = .03). Surgeons not performing outpatient TSA were more concerned with the potential of medical complications (P = .04). Perceived lack of experience (P = .002), low volume (P = .008), insurance contracts (P = .003), and reimbursement (P = .04) were less important barriers compared with outpatient TSA surgeons.

The authors note that as surgeons become more comfortable with outpatient TSA, there is a shift from concerns about medical complications to concerns about reimbursement.

Comment: There are many possible motivations for performing outpatient arthroplasty, including cost savings, patient convenience, marketing (Google "outpatient shoulder replacement"), surgeon ownership of an ambulatory operating facility, and other incentives. As physicians, our primary concern is the safety of the patient and the quality of the patient reported outcomes.  Further study is required to determine what patient characteristics, what surgeon experience, and what infrastructure elements are required to assure that the results of outpatient arthroplasty match those of inpatient arthroplasty. "Value" needs to be measured in terms of the benefit to the patient divided by the total cost of the procedure, including complications and readmissions.

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Use the "Search" box to the right to find other topics of interest to you.

How you can support progress in shoulder surgery

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Avoiding emergency visits after outpatient rotator cuff repair. Lessons learned

Unplanned emergency department or urgent care visits after outpatient rotator cuff repair:potential for avoidance

These authors reviewed 1306 outpatient RCR procedures in a closed health care system, and all unplanned emergency department (ED) and urgent care (UC) visits within 7 days of procedures were collected and compared with other typical outpatient orthopedic procedures (knee arthroscopy, carpal tunnel release, and anterior cruciate ligament reconstruction).

Avoidable diagnoses (ADs) for the unplanned visits were defined in advance as visits for (1) constipation, (2) nausea or vomiting, (3) pain, and (4) urinary retention.

Of the 729 male and 577 female patients; average age, 60 years, 90 returned for ED or UC visits (6.9%), with 34 for ADs (2.6%). 

Pain was the most common AD. However, when RCR was compared with other case types, ED or UC visits for urinary retention were significantly more common, whereas there was no significant difference with the other ADs. The 1306 RCRs led to a greater proportion of ED or UC visits than the combined 5825 other cases studied.

Comment: What is interesting about this paper is the actions the physicians in the system took to minimize the number of avoidable unplanned visits after cuff repair:

Preoperatively, patients receive counseling on pain management, constipation prevention, and return precautions. They are given prescriptions for postoperative pain to be filled the day before surgery. 

They recommended a single 375-mL glass of a high-carbohydrate clear liquid (eg, apple juice) up to 2 hours before arrival for surgery is used to help prevent constipation, nausea, and vomiting. 

Multimodal analgesia with acetaminophen, gabapentin, and a nonsteroidal antiinflammatory drug is started preoperatively for increased pain control and reduction of constipation, urinary retention risk, nausea, and vomiting. 

Perioperatively, monitored anesthesia care is preferred over general anesthesia whenever possible, and local anesthesia or field blocks are encouraged. 

Intravenous fluid restriction to less than 500 mLis also attempted to decrease the risk of urinary retention. 

Before discharge from the postanesthesia care unit, a concerted effort is made to ensure that a stool softener or laxative is prescribed for the patient.

This is a great example of a robust effort to identify issues with quality of patient care and cost, followed by a plan to address the problems identified.

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The reader may also be interested in these posts:

Healing through joint replacement

Supporting progress in shoulder surgery

Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book.

Click here to see the new Rotator Cuff Book

Information about shoulder exercises can be found at this link.

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

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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.

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Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book.

Click here to see the new Rotator Cuff Book

To see the topics covered in this Blog, click here

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'


See from which cities our patients come.

See the countries from which our readers come on this post.

Outpatient total shoulder arthroplasty - does it save money?

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."

======

Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book.

Click here to see the new Rotator Cuff Book

To see the topics covered in this Blog, click here

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'


See from which cities our patients come.

See the countries from which our readers come on this post.

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.

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Consultation for those who live a distance away from Seattle.

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.