Outpatient Shoulder Arthroplasty Research Articles

Multimodal pain management and postoperative outcomes in inpatient and outpatient shoulder arthroplasties: a population-based study

IntroductionMultimodal analgesia has been associated with reduced opioid utilization, opioid-related complications, and improved recovery in various orthopedic surgeries; however, large sample size data is lacking for shoulder surgery.MethodsA retrospective review...

Patient-selection algorithm for outpatient shoulder arthroplasty in ambulatory surgery center: a retrospective update

Outpatient total shoulder arthroplasty (TSA) presents a safe alternative to inpatient arthroplasty, while helping meet the rapidly rising volume of shoulder arthroplasty needs and minimizing health care costs. Identifying the correct patient for outpatient surgery is critical to maintaining the safety standards with TSA. This study sought to update an ambulatory surgery center (ASC) TSA patient-selection algorithm previously published by our institution. A retrospective chart review of TSAs was performed in an ASC at a single institution to collect patient demographics, perioperative risk factors, and postoperative outcomes with regard to reoperations, hospital admissions, and complications. The existing ASC algorithm for outpatient TSA was altered based on collected perioperative information, review of pertinent literature, and anesthesiology recommendations. A total of 319 TSAs were performed in an ASC in 298 patients over 7 years. Medically related complications occurred in 3 patients (0.9%) within 90 days of surgery, 2 of whom required hospital admission (0.6%) for acute kidney injury and pulmonary embolus. There were no instances of major cardiac events. Orthopedic-related complications occurred in 11 patients (3.4%), with hematoma development requiring evacuation and instability requiring revision being the most common causes. There was a low rate of perioperative complications and hospital admissions, confirming the safety of TSAs in an ASC setting. Based on prior literature and the population included, a pre-existing patient-selection algorithm was updated to better reflect increased comfort, knowledge, and data regarding safe patient selection for TSA in an ASC.

Outpatient Shoulder Arthroplasty In the Covid-19 Era: 90-Day Complications and Risk Factors

Outpatient Shoulder Arthroplasty In the Covid-19 Era: 90-Day Complications and Risk Factors

Outpatient shoulder arthroplasty in the COVID-19 era: 90-day complications and risk factors.

With the COVID-19 pandemic placing an increased burden on health care systems, shoulder arthroplasties are more commonly being performed as outpatient procedures. The purpose of this study was to characterize the 90-day episode-of-care complications of consecutive shoulder arthroplasties defaulted for outpatient surgery without using a prior algorithm for patient selection and to assess for their risk factors. We hypothesized that outpatient shoulder arthroplasty would be a safe procedure for all patients, regardless of patient demographics and comorbidities. A retrospective review of consecutive patients who underwent planned outpatient anatomic or reverse total shoulder arthroplasty between March 2020 and January 2022 with 3-month follow-up was performed. All patients were scheduled for outpatient surgery regardless of medical comorbidities. Patient demographics; pre/postoperative patient-reported outcomes including visual analog scale, subjective shoulder value, and American Shoulder and Elbow Surgeons score; pre/postoperative range of motion; and complications were collected from medical chart review. Multivariate logistic regression was used to identify predictors of the following outcomes: 1. Unplanned overnight hospital stay, 2. 90-day unplanned emergency department (ED)/clinic visit, 3. 90-day hospital readmission, 4. 90-day complications requiring revision. One hundred twenty-seven patients (47% male, 17% tobacco users, 18% diabetics) with a mean age 69±9years were identified, of whom 92 underwent reverse total shoulder arthroplasty and 35 underwent anatomic total shoulder arthroplasty. All patient-reported outcomes and range of motion were significantly improved at 3months. There were 15 unplanned overnight hospital stays (11.8%) after the procedure. Within 90days postoperatively, there were 17 unplanned ED/clinic visits (13.4%), 7 hospital readmissions (5.5%), and 4 complications requiring revision (3.1%). Factors predictive of unplanned overnight stay included age above 70years (odds ratio [OR], 36.80 [95% confidence interval [CI], 2.20-615.49]; P=.012), tobacco use (OR, 12.90 [95% CI, 1.23-135.31]; P=.033), and American Society of Anesthesiologists status of 3 (OR, 13.84 [95% CI, 1.22-156.57]; P=.034). The only factor predictive of unplanned ED/clinic visit was age over 70years old (OR, 7.52 [95% CI, 1.26-45.45]; P=.027). No factors were predictive of 90-day hospital readmission or revision. Outpatient shoulder arthroplasty is a safe procedure with excellent outcomes and low rates of readmissions and can be considered as the default plan for all patient undergoing shoulder arthroplasty. Patients who are above 70years of age, use tobacco, and have ASA score of 3, however, may be less suitable for outpatient arthroplasty and should be counseled regarding the higher risk of unplanned overnight hospitalization.

Distance and resources in vulnerable populations: understanding access barriers to outpatient shoulder arthroplasty

BackgroundOutpatient shoulder arthroplasty is advantageous in appropriately selected patients, and tools for performing selection are available. Whether vulnerable populations benefit from outpatient surgery despite being appropriate candidates clinically is unclear. We hypothesized that patient travel distance and resource level impact the ability to complete accelerated care pathways. MethodsA retrospective cohort of patients undergoing anatomic/reverse total shoulder arthroplasty at 2 geographically diverse, high-volume tertiary referral centers was created; 5406 cases were stratified into cohorts based on travel distance (0-49, 50-99, 100-150, and >150 miles). Sociodemographic, median income, and comorbidity data were collected. Short inpatient stay was utilized as a proxy for appropriateness for same-day discharge. Overall length of stay (LOS) and unplanned 90-day readmissions were collected as secondary outcomes. ResultsFour thousand one hundred one patients traveled 0-49 miles, 695 traveled 50-99 miles, 313 traveled 100-149 miles, and 297 traveled >150 miles for shoulder arthroplasty. Few significant differences in sociodemographic/comorbidity burdens were observed between distance cohorts. Increased distance outside of the immediate area (>50 miles) was significantly associated with decreased likelihood of short inpatient stay (P < .001) and increased LOS (P = .027) for Institution #1. For Institution #2, those in the shortest and longest distance groups had the shortest LOS (P = .018). Overall, patients living <50 miles had the highest income levels. A bi-modal income distribution was observed for Institution #1, while income decreased as distance increased for Institution #2. Unplanned 90-day readmission rates were not significantly different for either institution. DiscussionOverall, when examining demographic variables for the entire cohort representing both institutions, patient travel distance to a high-volume tertiary orthopedic center did not appear to be the primary driver for variability in early postoperative outcomes (ie, 90-day readmissions, short stay, LOS). For Institution 1, patients living further from surgery centers underwent short inpatient stay at lower rates relative to those nearby. Importantly, lower resource levels were seen as distance increased for both institutions, potentially limiting the ability to manage same-day discharge without additional assistance despite being clinically appropriate candidates for outpatient arthroplasty. Therefore, providing overnight lodging options and perioperative support for vulnerable populations may minimize disparities in access, while serving as a lower-cost-option.

Perioperative pain control represents the primary concern for patients considering outpatient shoulder arthroplasty: a survey-based study.

Outpatient (OP) total shoulder arthroplasty (TSA) with same-day discharge can now be performed safely in appropriately selected patients. Patient knowledge and perspectives regarding OP TSA are yet unknown and such information may inform surgeon decision-making and provide a framework for addressing patient concerns. The goal of this study was to understand and quantify patient knowledge of and concerns for OP TSA, with a working hypothesis that majority of patients are unaware of OP TSA as a realistic option and that their primary concern would be postoperative pain control. This was a retrospective cohort study at a tertiary care academic medical center including patients who underwent anatomic or reverse shoulder arthroplasty and completed an OP TSA expectations questionnaire/survey. This survey was provided preoperatively and included demographic factors, self-rated health evaluation, and perioperative expectations. Surveys evaluated whether patients undergoingTSA had any prior awareness of OP TSA and evaluated their primary concern with same-day discharge. Secondary questions included an assessment of patient expectations of outcomes of outpatient vs. inpatient surgery as well as their expected length of inpatient stay. A total of 122 patients who underwent anatomic and reverse shoulder arthroplasty completed the questionnaire and comprised the study cohort. Fifty-two (42.6%) of the patients were unaware that OP TSA was an option, and 26 (50%) of these were comfortable with the idea of OP TSA. Comfort with OP TSA was significantly associated with higher subjective patient-reported health status. Fifty-eight patients (47.5%) expected that following TSA they would require <24 hours of in-hospital postoperative care. The primary concern for patients considering OP TSA was postoperative pain control, endorsed by 44.3% of patients, compared with 13.1% of patients stating this would be their primary concern if admitted as an inpatient postoperatively. Pain control being a primary concern was significantly different between those considering outpatient vs. inpatient TSA. Most patients anticipated that OP shoulder arthroplasty would lead to a better (36%) or comparable (53%) outcome, whereas only 11% had concerns that it would lead to a worse outcome. Expanding OP TSA crucially depends on awareness and education. Perceived ability to control pain is an importantconcern. Patients may benefit from preoperative counseling, including emphasizing a comprehensive postoperative pain management strategy.

Procedure Cost Comparison of Outpatient and Inpatient Shoulder Arthroplasty and Lower-Extremity Arthroplasty Within a Managed-Care Organization.

Introduction The authors sought to evaluate cost differences between shoulder arthroplasties and lower-extremity joint replacements in the outpatient and inpatient setting within a large health-maintenance organization. Methods A cross-sectional study of 100 total hip arthroplasties (THA), 100 total knee arthroplasties (TKA), and 100 shoulder arthroplasties (50 anatomical total shoulder arthroplasties and 50 reverse shoulder arthroplasties [RTSA]) was performed at a single regional health care center within an integrated health care maintenance organization. A time-driven activity-based costing methodology was used to obtain total cost of each episode for outpatient (vs) inpatient surgery. Results are presented by procedure type. Results Compared to their respective inpatient procedure, outpatient surgery was less expensive by 20% for RTSA, 22% for total shoulder arthroplasties, 29% for THA, and 30% for TKA. The cost of implants was the highest proportion of cost for all joint procedures across inpatient and outpatient settings, ranging from 28% of the total cost for inpatient THA to 63% of the cost for outpatient RTSA. Discussion Although many factors influence the total cost for arthroplasty surgery, including rate of hospitalization, duration of stay, operative time, complexity of cases, patient factors, equipment, and resource utilization, the implant cost remains the most expensive factor, with hospital bed admission status being the second costliest contribution. Conclusion Outpatient total arthroplasty substantially reduced procedure expenses in a managed-care setting by 20%-30%, although savings for outpatient shoulder arthroplasty was lower than savings for THA or TKA. Implant costs remain the largest portion of shoulder arthroplasty procedure expenses.

Surgeon-administered intraoperative brachial plexus block for open shoulder surgery - a novel and safe technique.

In the era of outpatient shoulder surgery, bundled payment, safe, predictable, and time-efficient pain management strategies for shoulder arthroplasty (SA) are important. Ultrasound-guided interscalene blocks (ISBs), currently the gold standard for postoperative pain management after shoulder surgery, can be highly operator dependent, time-consuming, and not without complications. We developed a new surgical technique of surgeon-administered intraoperative brachial plexus block in patients undergoing SA open shoulder surgery using the deltopectoral approach. This procedure could be performed after the exposure, either at the beginning or end of the bony work. This procedure is simple, safe, and effective. We did not notice any complications that are typically seen with ISB-like respiratory depression secondary to phrenic nerve palsy, rebound pain after the block wore off, and pain related conversion of outpatient SA to inpatient, over the period of four years (2018-2022). This technique has additional advantages over the established "gold standard" ISB in terms of time and cost savings and improved operating room efficiency.

The transition to outpatient shoulder arthroplasty: a systematic review.

Transitioning shoulder arthroplasty (SA) from an inpatient to outpatient procedure is associated with increased patient satisfaction and potentially decreased costs; however, concerns exist about complications following same-day discharge. We hypothesized that outpatient SA would be associated with low rates of failed discharges, readmissions, and complications, rendering it a safe and effective option for SA. A systematic review of the outpatient SA literature identified 16 of 447 studies with level III and IV evidence that met the inclusion criteria with at least 90 days of follow-up. Data on patient demographic characteristics, preoperative and postoperative protocols, surgery characteristics, failed discharges, complications, and readmissions were collected and pooled for analysis. A total of 990 patients were included in our analysis. Many studies identified specific institutional protocols for determining eligibility for outpatient SA, including preoperative clearance from an anesthesiologist; identification of a perioperative caretaker; and exclusion of patients based on cardiac, pulmonary, or hematologic risk factors. Failed same-day discharge occurred in only 0.9% of patients (7 of 788), and 2.1% of patients (9 of 418) and 0.79% of patients (2 of 252) presented to an emergency department or urgent care facility for a perioperative concern. The readmission rate for periprosthetic fracture, arthrofibrosis, infection, subscapularis rupture, and anterior subluxation was 1.3% (7 of 529 patients). Complications occurred in 7.0% of patients (70 of 990), with 5.4% of patients (53 of 990) experiencing a surgical complication and 1.7% (17 of 990) having a medical complication. There were 28 total reoperations (2.9%, 28 of 955 patients). Outpatient SA is associated with low rates of failed discharges, readmissions, and complications. Additionally, the medical and surgical complications that occur after outpatient SA are unlikely to be prevented by the short inpatient stay characteristic of traditional SA. With careful screening measures to identify appropriate candidates for same-day discharge, outpatient SA represents a safe approach to prevent unnecessary hospitalizations and to decrease costs associated with SA.

Business Articles in Shoulder and Elbow Surgery Support Outpatient Total Shoulder Arthroplasty and Identify Factors Impacting Surgery Cost

Objectives: Review business related shoulder and elbow articles in tope general orthopaedic journals and compare to top shoulder and elbow subspecialty journals. Design: Literature review. Intervention: General orthopaedic vs subspecialty journals. Main outcome measurement: Publication type, subject, methods Results: There were a total of 21 shoulder and elbow related business articles across JBJS, B&amp;JJ, CORR, and AAOS during the study time period. That accounts for 0.3% of total publications (21/6098) and 8% of the business publications (21/261) in these journals over this 5 year span. Shoulder and elbow business publications accounted for a wide range of editorial space, ranging from 0% of CORR business publications to 11% of BJ&amp;J publications. Across the five shoulder and elbow surgery journals of interest, there were 57 business related articles published for the 5-year duration. The Journal of Shoulder and Elbow Surgery accounted for 77% of these publications (44/57). Business articles represented 0.8% of articles in the fine shoulder and elbow publications (57/7155) over the study time period. Conclusions:  This analysis demonstrates the tendency of shoulder and elbow oriented orthopaedic journals to publish a higher percentage of business articles related to shoulder and elbow surgery compared to general orthopaedics journal. The composition of these business articles demonstrates the recent focus on cost analysis of outpatient shoulder arthroplasty as well as factors that drive cost of shoulder and elbow procedures. The subject of shoulder and elbow business related articles in these journals over the last 5 years demonstrates that this field is increasingly interested in outpatient procedures and identifying ways to safely improve cost efficiency. Level of Evidence: IV review Keywords: Orthopaedic business, shoulder and elbow, cost, value based care, finance, shoulder arthroplasty, total shoulder. (J Ortho Business 2022; Volume 2, Issue 3:pages 18-31)

Ambulatory shoulder arthroplasty provides a mild reduction in overall cost compared with inpatient shoulder arthroplasty cost of ambulatory shoulder arthroplasty.

The purpose of this study was to determine the relative cost difference of inpatient vs. ambulatory total shoulder arthroplasty (TSA) procedures. A retrospective case series was performed to identify a consecutive series of patients who underwent primary anatomic or reverse TSA at 2 orthopedic specialty hospitals between September 2015 and August 2020. Those undergoing surgery for fracture or revision were excluded. Itemized facility costs were analyzed with a time-driven activity-based costing model and compared between ambulatory and non-ambulatory procedures. Ambulatory patients were defined as those admitted and discharged on the same calendar day. All other patients were considered non-ambulatory. A total of 1027 patients were analyzed, comprising 38 ambulatory patients (3.7%) and 989 non-ambulatory patients (96.3%). There was a higher proportion of anatomic TSA than reverse shoulder arthroplasty in the ambulatory group (81.6% vs. 51.7%, P<.0001). Overall, there was no difference in cost between the 2 groups ($8832 vs. $8841, P = .97). However, personnel costs were greater in the non-same-day group ($1895 vs. $2743, P < .0001) whereas supply costs were less ($6937 vs. $6097, P<.0003). When implant costs were excluded, outpatient shoulder arthroplasty provided a cost savings of $745. Ambulatory shoulder arthroplasty provides a mild cost savings of $745 after controlling for fixed costs. This is much less dramatic than previously reported and should raise concern as shoulder arthroplasty continues to be targeted by payers as a potential for cost savings through decreased reimbursement.

Appropriate patient selection for outpatient shoulder arthroplasty: a risk prediction tool.

The transition from inpatient to outpatient shoulder arthroplasty critically depends on appropriate patient selection, both to ensure safety and to counsel patients preoperatively regarding individualized risk. Cost and patient demand for same-day discharge have encouraged this transition, and a validated predictive tool may help decrease surgeon liability for complications and help select patients appropriate for same-day discharge. We hypothesized that an accurate predictive model could be created for short inpatient length of stay (discharge at least by postoperative day 1), potentially serving as a useful proxy for identifying patients appropriate for true outpatient shoulder arthroplasty. A multicenter cohort of 5410 shoulder arthroplasties (2805 anatomic and 2605 reverse shoulder arthroplasties) from 2 geographically diverse, high-volume health systems was reviewed. Short inpatient stay was the primary outcome, defined as discharge on either postoperative day 0 or 1, and 49 patient outcomes and factors including the Elixhauser Comorbidity Index, sociodemographic factors, and intraoperative parameters were examined as candidate predictors for a short stay. Factors surviving parameter selection were incorporated into a multivariable logistic regression model, which underwent internal validation using 10,000 bootstrapped samples. In total, 2238 patients (41.4%) were discharged at least by postoperative day 1, with no difference in rates of 90-day readmission (3.5% vs. 3.3%, P = .774) between cohorts with a short length of stay and an extended length of stay (discharge after postoperative day 1). A multivariable logistic regression model demonstrated high accuracy (area under the receiver operator characteristic curve, 0.762) for discharge by postoperative day 1 and was composed of 13 variables: surgery duration, age, sex, electrolyte disorder, marital status, American Society of Anesthesiologists score, paralysis, diabetes, neurologic disease, peripheral vascular disease, pulmonary circulation disease, cardiac arrhythmia, and coagulation deficiency. The percentage cutoff maximizing sensitivity and specificity was calculated to be 47%. Internal validation showed minimal loss of accuracy after bias correction for overfitting, and the predictive model was incorporated into a freely available online tool to facilitate easy clinical use. A risk prediction tool for short inpatient length of stay after shoulder arthroplasty reaches very good accuracy despite requiring only 13 variables and was derived from an underlying database with broad geographic diversity in the largest institutional shoulder arthroplasty cohort published to date. Short inpatient length of stay may serve as a proxy for identifying patients appropriate for same-day discharge, although perioperative care decisions should always be made on an individualized and holistic basis.

Trends in outpatient shoulder arthroplasty during the COVID-19 (coronavirus disease 2019) era: increased proportion of outpatient cases with decrease in 90-day readmissions.

BackgroundThe COVID-19 (coronavirus disease 2019) pandemic has placed an increased burden on health care resources, with hospitals around the globe canceling or reducing most elective surgical cases during the initial period of the pandemic. Simultaneously, there has been an increased interest in performing outpatient total joint arthroplasty in an efficient manner while maintaining patient safety. The purpose of this study was to investigate trends in total shoulder arthroplasty (TSA) during the COVID-19 era with respect to outpatient surgery and postoperative complications.MethodsWe conducted a retrospective chart review of all primary anatomic and reverse TSAs performed at our health institution over a 3-year period (January 2018 to January 2021). All cases performed prior to March 2020 were considered the “pre–COVID-19 era” cohort. All cases performed in March 2020 or later comprised the “COVID-19 era” cohort. Patient demographic characteristics and medical comorbidities were also collected to appropriately match patients from the 2 cohorts. Outcomes measured included type of patient encounter (outpatient vs. inpatient), total length of stay, and 90-day complications.ResultsA total of 567 TSAs met the inclusion criteria, consisting of 270 shoulder arthroplasty cases performed during the COVID-19 era and 297 cases performed during the pre–COVID-19 era. There were no significant differences in body mass index, American Society of Anesthesiologists score, smoking status, or distribution of pertinent medical comorbidities between the 2 examined cohorts. During the COVID-19 era, 31.8% of shoulder arthroplasties were performed in an outpatient setting. This was significantly higher than the percentage in the pre–COVID-19 era, with only 4.5% of cases performed in an outpatient setting (P < .0001). The average length of stay was significantly reduced in the COVID-19 era cohort (0.81 days vs. 1.45 days, P < .0001). There was a significant decrease in 90-day readmissions during the COVID-19 era. No significant difference in 90-day emergency department visits, 90-day venous thromboembolism events, or 90-day postoperative infections was observed between the 2 cohorts.ConclusionWe found a significant increase in the number of outpatient shoulder arthroplasty cases being performed at our health institution during the COVID-19 era, likely owing to a multitude of factors including improved perioperative patient management and increased hospital burden from the COVID-19 pandemic. This increase in outpatient cases was associated with a significant reduction in average hospital length of stay and a significant decrease in 90-day readmissions compared with the pre–COVID-19 era. The study data suggest that outpatient TSA can be performed in a safe and efficient manner in the appropriate patient cohort.

Inpatient versus outpatient shoulder arthroplasty outcomes: A propensity score matched risk-adjusted analysis demonstrates the safety of outpatient shoulder arthroplasty

ObjectivesBeginning January 1, 2021 total shoulder arthroplasty (TSA) was removed from the Medicare (U.S national healthcare for patients ≥ 65years of age) inpatient-only list. Furthermore, there is limited data comparing outpatient and inpatient TSA among recent contemporary large population databases. This study aimed to analyze shoulder arthroplasty outcomes between inpatient and outpatient procedures at the national level. MethodsThe American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was utilized (2015–2019). Cases with a current procedural terminology of 23472 indicative of primary TSA and reverse total shoulder arthroplasty were included (N = 22,452). Outcomes were then analyzed in two approaches: unmatched analysis and propensity score matched risk-adjusted analysis. ResultsOverall, 9.7% (N = 2,185) of cases were performed outpatient and 90.3% (N = 20,357) of cases were performed inpatient. The rate of outpatient procedures has been steadily increasing (2015: 8.3%, 2016: 14.7%, 2017: 15.8%, 2018: 26.5%, 2019: 34.6%; P < 0.001). Outpatients were more likely to be male (50.7% vs. 43.7%) and younger (age < 65; 37.0% vs. 27.9%) and less likely to be ASA class 3 or 4 (49.5% vs. 58.3%). Outpatients had fewer comorbidities including obesity (46.1% vs. 51.9%), hypertension (60.5% vs. 67.4%), diabetes (15.1 vs. 18.2%), chronic obstructive pulmonary disease (4.8% vs. 7.0%), bleeding disorders (1.3% vs. 2.5%), or chronic steroid use (3.5% vs. 5.0%; all P < 0.001). In a non-risk matched analysis of outcomes, outpatient procedures displayed lower rates of any adverse event (3.5% vs. 5.3%; P < 0.001), minor adverse events (1.5% vs. 3.0%; P = 0.001), and readmission (2.2% vs. 2.8%; P = 0.025). Following a propensity score matched analysis, two risk matched cohorts of outpatient (N = 2,172) and inpatient (N = 2,172) procedures were identified. Subsequent analysis of outcomes revealed no significant differences in outcome metrics between risk-matched outpatient and inpatient procedures. ConclusionsFrom 2015 to 2019, there has been a four-fold increase in the proportion of outpatient shoulder arthroplasty cases in the ACS-NSQIP database. This study shows that outpatient shoulder arthroplasty may be safely performed in a select cohort of patients without increased risk of adverse events. After adjusting for comorbidities, there were no differences in clinical outcomes or rates of adverse outcomes between inpatient and outpatient shoulder arthroplasty. Level of evidenceRetrospective Observational Study, Level IV.

Outpatient Shoulder Arthroplasty Patient Selection, Patient Experience, and Cost Analyses: A Systematic Review.

The utilization of outpatient shoulder arthroplasty has been increasing. With increasing pressure to reduce costs, further underscored by the coronavirus (COVID-19) pandemic, many health-care organizations will move toward outpatient interventions to conserve inpatient resources. Although abundant literature has shown the advantages of outpatient total hip arthroplasty (THA) and total knee arthroplasty (TKA), there is a relative paucity describing outpatient shoulder arthroplasty. Thus, the purpose of this study was to summarize the peer-reviewed literature of outpatient shoulder arthroplasty with particular attention to patient selection, patient outcomes, and cost benefits. The PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Embase databases were queried according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. All articles on outpatient shoulder arthroplasty were included. Data on patient selection, patient outcomes, and cost analyses were recorded. Patient outcomes, including complications, reoperations, and readmissions, were analyzed by weighted average. Twenty-three articles were included for analysis. There were 3 review articles and 20 studies with Level-III or IV evidence as assessed per The Journal of Bone & Joint Surgery Level of Evidence criteria. Patient selection was most often predicated on age <70 years, body mass index (BMI) <35 kg/m2, absence of active cardiopulmonary comorbidities, and presence of home support. Complications and readmissions were not common and either improved or were equivalent to those of inpatient shoulder arthroplasty. Patient satisfaction was high in studies of short-term and intermediate-term follow-up. The proposed cost benefit ranged from $747 to $53,202 with outpatient shoulder arthroplasty. The published literature to date supports outpatient shoulder arthroplasty as an effective, safe, and cost-reducing intervention with proper patient selection. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Predicting length of stay after shoulder arthroplasty

Background/HypothesisThe annual volume of shoulder arthroplasty (SA) in the United States has increased more than 400% from 1993 to 2008 and is projected to increase an additional 300% from 2008 to 2030. The purpose of this study was to develop and internally validate a preoperative predictive nomogram for length of stay (LOS) after SA. We hypothesized that patient-specific covariates are responsible for increased LOS after SA. If sufficiently accurate, such a nomogram would be valuable for defining which patients would qualify for outpatient SA. MethodsA systematic review of the literature was performed to identify patient variables responsible for increased LOS defined as ≥ 2 days. Patient data were collected from 234 consecutive SA cases performed between 2010 and 2016 at a single tertiary healthcare center by six orthopedic surgeons. The cohort was separated into two groups: short LOS (≤1 day; n = 98) and extended LOS (≥2 days; n = 136). Logistic regression coefficients were used to construct an LOS nomogram that was internally validated by the bootstrapping method. A receiver operating characteristic curve plot determined the discriminative ability of the nomogram. Generalizability was assessed using external validation with a new data set of 193 records prospectively collected from 2016 to 2018. ResultsUnivariate analysis demonstrated that female sex, cancer history, anticoagulation and oral hypoglycemic agents, undergoing humeral head replacement for fracture, and discharge to a facility were significant predictors for an LOS ≥2 days. The following patient covariates were found to be significant in the development of the nomogram: age, female sex, procedure type, disease-modifying antirheumatic drugs (DMARDs), renal dysfunction, and diabetes drugs. The prediction accuracy of this model was good (area under the curve of the receiver operating characteristic curve plot of 0.793). External validation of the model reported an area under the curve of 0.664. ConclusionPatients most suitable for expedited postoperative stay are healthy middle-aged males that are not on diabetic medications or DMARDs, have no renal disease, and undergo resurfacing, total SA, or reverse total SA. This nomogram may be an additional clinical decision-making tool for effectively preparing for postoperative care and decreasing LOS for an episode of care, subsequently reducing the total cost of care. Future work would focus on undertaking a prospective multicenter study involving institutions that perform a high annual volume of SAs. Level of evidenceLevel III; Retrospective Cohort Study

204 A Systematic Review of Clinical Outcomes for Outpatient vs Inpatient Shoulder Arthroplasty

Abstract Aim Outpatient shoulder arthroplasty is growing in popularity as a cost-effective and potentially equally safe alternative to inpatient arthroplasty. We investigated literature relating to outpatient shoulder arthroplasty, looking at clinical outcomes, complications, readmission, and cost compared to inpatient arthroplasty. Method We systematically searched Medline, Embase, PubMed using relevant search terms. Methodological quality of included studies was assessed using Methodological Index for Non-Randomised Studies score. Results We included 17 studies in our review with 11 included in the meta-analyses. A meta-analysis of hospital readmissions demonstrated that there was no statistically significant difference between outpatient and inpatient cohorts (OR = 0.89, 95% CI: 0.63-1.25, p = 0.49, I2=56%). Pooling results for all post-operative complications identified decreased complications in those undergoing outpatient surgery (OR = 0.70; 95% CI: 0.52-0.94, p = 0.02, I2=50%). No statistically significant difference was identified with respect to medical complications (OR = 0.86, 95% CI: 0.74-1.01, p = 0.07, I2=0%) or surgical complications (OR = 0.71, 95% CI: 0.45-1.12, p = 0.14, I2=26%). Considerable cost saving of between $3 614 – $53 202 (19.7 – 69.9%) per patient were present in the outpatient setting. Conclusions Shoulder arthroplasty in the outpatient setting is as safe as shoulder arthroplasty in the inpatient setting, with a significant reduction in cost. There is no demonstrable statistically significant difference with regards to readmissions between outpatient and inpatient shoulder arthroplasty. In the appropriately selected patient, outpatient shoulder arthroplasty is safe and cost-effective; however, we still need to work towards understanding who the appropriate patients are for this post-operative care pathway.

Candidacy for ambulatory outpatient shoulder arthroplasty: a retrospective review

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.

Current Status Regarding the Safety of Inpatient Versus Outpatient Total Shoulder Arthroplasty: A Systematic Review.

Surgeons have begun to transition total shoulder arthroplasty (TSA) to the outpatient setting in order to contain costs and reallocate resources. The purpose of this systematic review was to evaluate the safety and cost of outpatient TSA by assessing associated complication rates, clinical outcomes, and total treatment charges. The MEDLINE, Embase, and Cochrane Library online databases were queried in March 2020 for studies on outpatient shoulder arthroplasty. Inclusion criteria were (1) a study population undergoing TSA, (2) discharge on the day of surgery, and (3) inclusion of at least 1 reported outcome. Of 20 studies identified that met inclusion criteria, 14 were comparative studies involving an inpatient control group, 2 of which were matched by age and comorbidities. The remaining studies used control groups consisting of inpatient TSAs who were older or more medically infirm according to American Society of Anesthesiologists (ASA) or Charlson Comorbidity Index (CCI) scores. The combined average age of the outpatient and inpatient groups was 66.5 and 70.1 years, respectively. Patients who underwent outpatient TSA had similar rates of readmissions, emergency department visits, and perioperative complications in comparison to inpatients. Patients also reported comparably high levels of satisfaction with outpatient procedures. Four economic analyses demonstrated substantial cost savings with outpatient TSA in comparison to inpatient surgery. In carefully selected patients, outpatient TSA appears to be equally safe but less resource intensive than inpatient arthroplasty. Nonetheless, there remains a need for larger prospective studies to decisively characterize the relative safety of outpatient TSA among patients with similar baseline health.

Reemplazo de hombro ambulatorio: Presentación de protocolo perioperatorio y resultados iniciales

BackgroundShoulder arthoplasty is an effective procedure to improve pain and function in chronic shoulder pathologies. Considering the risks and costs associated with hospital stay, performing joint replacements on an outpatient setting emerges as an option to optimize this therapeutic strategy. MethodsA prospective analysis was performed in 10 patients undergoing same-day discharge total shoulder arthroplasty with anatomic and reverse prostheses. Pain was managed with a continuous peripheral interscalene block using an elastomeric infusion pump. ASES and SANE scores, pain, patient satisfaction, complications, and readmissions after 90 days were recorded. Results10 patients (average age 59.6 (±3.9) years) underwent outpatient shoulder arthroplasty (50% reverse shoulder arthroplasty, 40% total shoulder arthroplasty and 10% hemiarthroplasty). On post-operative day 4, mean visual analogue scale (VAS) for pain assessment was 1.3 (±0.62) and day 10, 2.7 (±1.1). Pre-operative SANE score was 31 (±9.7), and 90 days after the procedure was 76.1 (±6.8). All patients were satisfied with the procedure. One patient had a mild bronchospasm on day 3 that resolved with bronchodilators on an outpatient basis. One patient had a superficial surgical site infection that resolved completely with oral antibiotics administration. There were no re-admissions or major complications. DiscussionWe present short- to medium-term outcomes of the first case series in our setting of shoulder replacement performed with same-day discharge. This procedure can be performed safely, following a standardized protocol and making a judicious selection of patients.