Candidacy for ambulatory outpatient shoulder arthroplasty: a retrospective review

Abstract

BackgroundOutpatient shoulder arthroplasty performed in an ambulatory surgery center has been shown to be a safe and cost-effective practice in appropriately selected patients. The decision to proceed with outpatient shoulder arthroplasty is based on a multitude of factors, including the patient's overall medical status, insurance type, social factors, and complexity of shoulder pathology. Currently, there is a paucity of literature that exists identifying the main drivers in determining in which setting, outpatient or inpatient, shoulder arthroplasty is performed. MethodsA retrospective chart review of 1017 patients who underwent total shoulder arthroplasty (TSA) or reverse total shoulder arthroplasty at a single institution between January 2014 and February 2020 was performed. Each patient was screened for medical candidacy using a previously described evidenced-based patient selection algorithm based on age and cardiopulmonary risk factors. Clinical documentation and billing records were reviewed to determine the setting in which the shoulder arthroplasty was performed and the primary factors for determining inpatient shoulder arthroplasty. ResultsOverall 837 (82.3%) arthroplasties were performed inpatient, with at least a 23-hour hospital stay, and 180 (17.7%) were performed outpatient at a free-standing ambulatory orthopedic surgery center. The patient selection algorithm identified 522 (51.3%) patients as medical candidates for outpatient surgery. Poor candidacy based on medical risk stratification (495; 59.1%) and government insurance payors (231; 27.6%) were the most common reasons for a procedure to be performed in an inpatient setting. Among those deemed appropriate outpatient candidates but who had surgery in an inpatient setting, insurance status (231; 67.5%) was the most common reason, whereas additional medical or social concerns represented a smaller proportion (40; 11.7%). Eliminating shoulder arthroplasty as an inpatient-only code would have effectively transitioned 231 patients, 22.7% of the entire cohort, from an inpatient setting to an outpatient setting. ConclusionsMedical stratification and insurance status both contribute significantly toward the decision to perform shoulder arthroplasty outpatient. Should policy change occur that eliminates shoulder arthroplasty from the Centers for Medicare and Medicaid Services inpatient-only distinction, a significant increase in outpatient shoulder arthroplasty volume would be expected. In the absence of insurance requirements, our data suggest that 40.4% of patients could safely undergo shoulder arthroplasty in an outpatient setting. Level of EvidenceLevel III, retrospective comparative study.