Outpatient Total Knee Arthroplasty Shows Decreasing Complication Burden From 2010 to 2020

Predictors of failing same-day discharge after shoulder arthroplasty: developing a model to improve outcomes and reduce health care cost

BACKGROUND

With increasing efforts to transition shoulder arthroplasty to the ambulatory surgery setting, there is increased interest in predictive factors of failure of same-day discharge (SDD). The purpose of this study was to identify predictors of failing SDD, defined as requiring at least an overnight hospital stay after shoulder arthroplasty, and to develop a predictive model to identify which patients may require postoperative hospital admission.

METHODS

A retrospective review of a consecutive series of patients with rotator cuff arthropathy or osteoarthritis treated with primary anatomic or reverse total shoulder arthroplasty between January 2019 and June 2023 was conducted. Inclusion criteria included patients intended for SDD, whereas patients who underwent arthroplasty for fractures, patients younger than 45 years, and patients with incomplete data were excluded. Data on demographics, Charlson Comorbidity Index, preoperative opioid use, and preoperative steroid injections were collected. In addition, intraoperative metrics including American Society of Anesthesiologists score, surgical/anesthesia time, surgical start time, and blood loss were recorded. Multivariate logistic regression was used to identify predictors of failure of SDD. Results were displayed as odds ratios (OR) and 95% confidence intervals. The α threshold was set to P < .05.

RESULTS

A total of 333 patients (69 anatomic total shoulder arthroplasty and 264 reverse total shoulder arthroplasty) were included with 92 failures of SDD (27.6%). According to multivariate results, we found older age (OR: 1.44, P = .004), anesthesia start time per hour later in the day (OR: 6.03, P = .017), preoperative opioid use within the past year (OR: 1.82, P = .046), and female sex (OR: 2.76, P = .001) as statistically significant risk factors for not achieving SDD. In addition, each half-hour increase in length of time under anesthesia was statistically significant, increasing odds of failing SSD by 4.28 per half hour (P < .001). A diagnosis of rotator cuff arthropathy had 3.40 greater odds of failing to achieve SDD as compared with a diagnosis of osteoarthritis (P < .001). Overall, the model had a high level of predictability, yielding a receiver operating characteristic curve area under the curve of 83%.

CONCLUSIONS

Older age, rotator cuff arthropathy, female sex, preoperative opioid use, and prolonged anesthesia exposure were significant predictors of failure of SDD after shoulder arthroplasty. These results support the utility in risk stratification strategies of patients to accurately triage them into SDD pathways. In addition, our results suggested that collaboration between surgeons and anesthesia teams may allow for more accurate risk stratification and optimization of resource utilization when deciding which patients are appropriate candidates for SDD.

Oral Postoperative Antibiotic Prophylaxis for Outpatient Total Hip and Knee Arthroplasty: Describing Current Practices

BACKGROUND

Despite an increase in outpatient total hip arthroplasty (THA) and total knee arthroplasty (TKA), large-scale data are lacking on current practice for antibiotic prophylaxis prescribing. We aimed to describe current oral antibiotic prophylaxis practices nationally for outpatient THA and TKA.

METHODS

This nationwide retrospective cohort study included primary outpatient THA or TKA procedures in patients aged 18 to 64 years from 2018 to 2021 using a national claims database. Oral antibiotic prescriptions filled perioperatively (defined as 5 days before to 3 days after surgery) were extracted; these were categorized and assumed to represent postoperative prophylaxis. Multivariable logistic regression measured associations between patient and surgery characteristics and perioperative oral antibiotic prophylaxis. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) are reported.

RESULTS

Oral antibiotic prescriptions were filled in 16.5% of 73,015 outpatient THA and TKA (18.4% of 24,857 THAs, 15.5% of 48,158 TKAs) procedures. Prescriptions were most often for cephalosporins (74.3%), with cephalexin (52.8%), and cefadroxil (19.1%) being the most common. Non-cephalosporin antibiotics prescribed were mainly clindamycin (6.8%), sulfamethoxazole-trimethoprim (6.7%), and doxycycline (6.2%). The odds of receiving oral antibiotic prophylaxis were higher for THA compared to TKA (OR 1.13, 95% CI 1.09 to 1.18, P < .001) and in the presence of obesity, diabetes, and autoimmune conditions (OR 1.08 to 1.13, P < .001 to .01). Ambulatory surgery center procedures also had significantly increased odds of prophylaxis compared to hospital-based outpatient surgeries (OR 2.62, 95% CI 2.51 to 2.73, P < .001). Additionally, regional and time-based variations were noted.

CONCLUSIONS

Perioperative oral antibiotic prophylaxis prescriptions were filled in only 16.5% of outpatient THA and TKA cases, with variation in the type of antibiotic prescribed. The receipt of any prophylaxis and specific medications was associated with demographic, clinical, and procedure-related characteristics. Follow-up research will evaluate associations with infection risk reduction.

Inpatient vs outpatient arthroplasty: A in-state database analysis of 90-day complications

Introduction

An increase in the number of policy initiatives, such as alternative payment models, have prompted healthcare providers to examine health-care expenditures while seeking to improve quality of care. Performing total joint arthroplasty (TJA) in the outpatient setting is an attractive option in driving costs down and providing psychological benefits to patients. Concerns regarding the safety and effectiveness of same-day discharge protocols warrants further investigation, especially on the state level. Due to the lack of consensus, we aimed to compare: (1) risk factors for outpatient arthroplasty and (2) incidences of postoperative complications between inpatient vs outpatient arthroplasty using an in-state database.

Methods

Patients who underwent total knee or hip arthroplasty between January 1, 2022 and December 31, 2022 were identified. Data was drawn from the Maryland State Inpatient Database (SID) and Maryland State Ambulatory Surgery and Services Database (SASD). A total of 7817 patients had TJA within this time. Patients were divided into inpatient arthroplasty (n = 1429) and outpatient arthroplasty (n = 6338). Demographic variables, medical comorbidities, and 90-day complication rates were compared between inpatient and outpatient procedures. Additional independent variables included: marital status, primary language, race, and median household income. A multivariate logistic regression analysis was performed to identify independent risk factors for complications following TJA after controlling for risk factors and patient comorbidities.

Results

Arthroplasty in the outpatient setting were more likely to be married (61.3% vs. 51.2%, p < 0.001), white (75.5% vs. 60.9%, <0.001), speak English as primary language (98.7% vs. 88.6%, p < 0.001), and have lower rates of diabetes (4.8% vs. 9.7%, p < 0.001), chronic obstructive pulmonary disease (16.3% vs. 21.8%, p < 0.001), and obesity (30.0% vs. 45.2%, p < 0.001) compared to arthroplasty in the inpatient setting, respectively. There were lower incidences of acute kidney injury (0.2 vs. 0.8%, p < 0.001) and infection (0.3% vs. 1.1%, p < 0.001) in the outpatient cohort compared to the inpatient cohort, respectively. Inpatient arthroplasty (Odds Ratio (OR) 1.98, 95% CI 1.30-3.02, p = 0.002) and hypertension (OR 2.12, 95% CI 1.23-3.64, p = 0.007) were independent risk factors for total complications following TJA.

Conclusion

Arthroplasty in the outpatient setting showed fewer complications than compared to patients in the inpatient setting. Although multiple factors should guide the decision for arthroplasty, outpatient arthroplasty may be a safe option for select, healthier patients without the increased burden of increased complications.