Safety and Cost Effectiveness of Outpatient Total Shoulder Arthroplasty

A Systematic Review

Tyler E. Calkins, MD; Zachary A. Mosher, MD; Thomas W. Throckmorton, MD; Tyler J. Brolin, MD

Disclosures

J Am Acad Orthop Surg. 2022;30(2):e233-e241. 

In This Article

Abstract and Introduction

Abstract

Introduction: Changes in healthcare policy have driven many hospital-based surgeries to the outpatient environment. Multiple studies have shown outpatient total shoulder arthroplasty (TSA) is a safe alternative to the inpatient setting. This systematic review evaluates patient selection, perioperative protocols, complications, costs, patient satisfaction, and clinical outcomes of outpatient TSA and compares these with their inpatient counterparts.

Methods: The Emnbase, Medline, and CENTRAL databases were queried on April 30, 2020, for outpatient TSA studies, identifying 232 articles, with 21 meeting inclusion criteria. This involved 25,808 and 231,408 patients undergoing outpatient and inpatient TSA, respectively. Failed same-day discharge, readmissions, revision surgeries, cost, and complications among outpatient TSA were aggregated when raw numbers were available. Statistical significance for comparisons among outpatient and inpatient TSA within individual studies was alpha = 0.05.

Results: Ten studies evaluated same-day discharge rate, with 440 of 446 patients (98.7%) meeting the goals. Fourteen studies evaluated readmissions, revision surgeries, and complications, with readmissions in 238 of 6,133 patients (3.9%), revision surgeries in 32 of 1,484 patients (2.1%), and complications in 376 of 4,977 patients (7.6%). Readmission rates were similar between inpatients and outpatients, with only one study finding more readmissions after inpatient TSA. Complications were more common in inpatient TSA in five studies. Outpatient TSA demonstrated a charge reduction of $25,509 to $53,202 per patient, and patient satisfaction after outpatient TSA was "good to excellent" in more than 95% of patients. Patient selection for outpatient TSA used patient age, medical comorbidities, social support, living proximity to location of surgery, and lack of preoperative opioid use.

Discussion: Outpatient TSA in appropriately selected patients is a safe and cost-effective alternative to inpatient TSA. However, the literature is limited to national database or small retrospective studies. Large prospective, cohort studies are necessary to further assess differences in complication profiles between outpatient and inpatient TSA.

Level of Evidence: Level IV; systematic review

Introduction

Total joint arthroplasty is an established treatment for end-stage degenerative conditions. Total hip (THA) and knee (TKA) arthroplasty are more common with widespread usage for the last 50 years, but total shoulder arthroplasty (TSA) has become increasingly popular and is increasing in utilization at the highest rate of all arthroplasty options.[1,2] Previous studies have shown that complications, cost, and hospital length of stay (LOS) may be less among patients undergoing TSA compared with THA and TKA.[3] In addition, more patients seeking TSA are younger,[4] leading to increased interest in outpatient and same-day discharge (SDD) pathways.[5] Initial reports of outpatient TKA and THA began in 2004 and 2005[6] with good results, and small outpatient TSA reports within the anesthesia literature followed in 2005[7] and 2008.[8] However, over a decade later in 2016, reports appeared discussing outpatient TSA.[9,10] Outpatient TKA and THA have been described in recent systematic reviews as safe and practical alternatives to their inpatient counterparts, whereas limited similar reviews are available for TSA at this time.[5,11–13]

Improvements in surgical technique, perioperative management, multimodal pain control, and early postoperative rapid rehabilitation pathways have offered surgeons and patients the ability to participate in outpatient TSA.[14] The economic environment also is a prominent driver for performing more arthroplasty procedures in the outpatient setting because it is shown to reduce the costs without sacrificing quality.[15–22] Several studies have assessed outpatient TSA, with many comparing it with inpatient TSA.[7–10,20–36] The purpose of this review was to evaluate patient selection, perioperative protocols, complications, costs, patient satisfaction, and clinical outcomes of outpatient TSA and compare these with their inpatient counterparts. We hypothesized that outpatient TSA will perform as well as inpatient TSA, with appropriate patient selection and perioperative management with acceptable complication profiles and planned SDD rates.

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