Is outpatient shoulder arthroplasty safe in patients aged ≥65 years? A comparison of readmissions and complications in inpatient and outpatient settings

Outpatient versus inpatient total shoulder arthroplasty: A meta-analysis of clinical outcomes and adverse events

BACKGROUND

In recent years, orthopaedic procedures have increasingly shifted from inpatient to outpatient settings. This trend includes total shoulder arthroplasty (TSA), which is being performed more frequently in outpatient facilities and ambulatory surgical centres. The purpose of this study was to compare the clinical outcomes and rates of adverse events between outpatient and inpatient TSA.

METHODS

PubMed, Cochrane, and Google Scholar (pages 1-20) databases were screened for articles comparing outpatient to inpatient TSA through June 2024, using relevant and holistic search terms. Non-comparative articles and those utilizing national databases were excluded from our study. Data on complications, myocardial infarction (MI), thromboembolic events, anaemia/transfusions, infections, readmissions, emergency department (ED) visits, revision surgery, and patient reported outcome measures at one year (Visual Analog Scale [VAS] and American Shoulder and Elbow Surgeons [ASES] score) were extracted.

RESULTS

A total of 14 articles were included in our study, involving 1070 outpatient and 1330 inpatient TSA patients. Patients in the inpatient group were older and had a higher ASA compared to the patients in the outpatient group. The outpatient TSA group was found to have significantly lower rates of overall complications (odds ratio [OR] = 0.59, p = 0.001), medical complications (OR = 0.43, p < 0.001), and readmissions (OR = 0.47, p = 0.008), as well as higher mean ASES scores (81.4 vs. 78.5, p = 0.01) when compared to the inpatient TSA group. There were no significant differences in rates of ED visits (p = 0.27), revisions (p = 0.06), and VAS scores (p = 0.15) between inpatient and outpatient TSA groups.

CONCLUSION

TSAs performed in the outpatient setting had a lower rate of overall adverse events, medical complications, readmissions, and a higher ASES score compared to inpatient TSAs. However, since patients in the inpatient group had higher ASA and were older, our results support the safety of the outpatient TSA based on the current selection criteria.

Same-day discharge vs. inpatient total shoulder arthroplasty: an age stratified comparison of postoperative outcomes and hospital charges

BACKGROUND

As the number of total shoulder arthroplasty (TSA) procedures increases, there is a growing interest in improving patient outcomes, limiting costs, and optimizing efficiency. One approach has been to transition these surgeries to an outpatient setting. Therefore, the purpose of this study was to conduct an age-stratified analysis comparing the 90-day postoperative outcomes of primary TSA in the same-day discharge (SDD) and inpatient (IP) settings with a specific focus on the super-elderly.

METHODS

This retrospective study included all patients who underwent primary anatomic or reverse TSA between January 2018 and December 2021 in ambulatory and IP settings. The outcome measures included length of stay (LOS), complications, hospital charges, emergency department (ED utilization), readmissions, and reoperations within 90 days following TSA. Patients with LOS ≤8 hours were considered as SDD, and those with LOS >8 hours were considered as IP. P < .05 was considered statistically significant.

RESULTS

There were 121 and 174 procedures performed in SDD and IP settings, respectively. There were no differences in comorbidity indices between the SDD and IP groups (American Society of Anesthesiologists score P = .12, Elixhauser Comorbidity Index P = .067). The SDD cohort was younger than the IP group (SDD 67.0 years vs. 73.0 IP years, P < .001), and the SDD group higher rate of intraoperative tranexamic acid use (P = .015) and lower estimated blood loss (P = .009). There were no differences in 90-day overall minor (P = .20) and major complications (P = 1.00), ED utilization (P = .63), readmission (P = .25), or reoperation (P = .51) between the SDD and IP groups. When stratified by age, there were no differences in overall major (P = .80) and minor (P = .36) complications among the groups. However, the LOS was directly correlated with increasing age (LOS = 8.4 hours in ≥65 to <75-year cohort vs. LOS = 25.9 hours in ≥80-year cohort; P < .001). There were no differences in hospital charges between SDD and IP primary TSA in all 3 age groups (P = .82).

CONCLUSION

SDD TSA has a shorter LOS without increasing postoperative major and minor complications, ED encounters, readmissions, or reoperations. Older age was not associated with an increase in the complication profile or hospital charges even in the SDD setting, although it was associated with increased LOS in the IP group. These results suggest that TSA can be safely performed expeditiously in an outpatient setting.

A Systematic Review of Patient Selection Criteria for Outpatient Total Shoulder Arthroplasty

The utilization of total shoulder arthroplasty (TSA) is increasing, driving associated annual health care costs higher. Opting for outpatient over inpatient TSA may provide a solution by reducing costs. However, there is no single set of accepted patient selection criteria for outpatient TSA. Here, the authors identify and systematically review 14 articles to propose evidence-based criteria that merit postoperative admission. Together, the studies suggest that patients with limited ability to abmluate independently or a history of congestive heart failure may benefit from postoperative at least one night of hospital based monitoring and treatment.

Outpatient vs. inpatient total shoulder arthroplasty: complication rates, clinical outcomes, and eligibility parameters

Background

Improvements in total shoulder arthroplasty (TSA), fast-track surgery, multimodal anesthesia, and rehabilitation protocols have opened up the possibility of outpatient care that is now routinely practiced at our European institution. The first objective of this study was to define the TSA outpatient population and to verify that outpatient management of TSA does not increase the risk of complications. The second objective was to determine patient eligibility parameters and the third was to compare functional outcomes and identify influencing factors.

Methods

The study included 165 patients who had primary TSA (106 outpatient and 59 inpatient procedures). The operative technique was the same for both groups. Demographics, complications, readmissions, and revisions were collected. American Society of Anesthesiologists, Constant, American Shoulder and Elbow Surgeons, University of California Los Angeles shoulder, and Shoulder Pain and Disability Index scores were obtained preoperatively and at 1.5, 6, and 12 months postoperatively. Satisfaction and visual analog scale pain scores also were documented. Statistical analysis was completed using multivariate linear regression.

Results

Outpatients were significantly younger and had lower American Society of Anesthesiologists scores than inpatients. The rates of complications, readmissions, and reoperations were not significantly different between groups. Outpatient surgery was not an independent risk factor for complications. At 1.5 months, better outcomes were noted in the outpatient group for all scores, and these reached statistical significance. Distance to home, dominant side, operative time, and blood loss were not associated with functional results. Multivariate analysis demonstrated that outpatient care was significantly associated with improved scores at 1.5 months and did not affect functional outcomes at 6 and 12 months.

Conclusion

This study reports the results of routine outpatient TSA within a European healthcare system. TSA performed in an outpatient setting was not an independent risk factor for complications and seemed to be an independent factor in improving early functional results.

Identifying risk factors for 30-day readmission after outpatient total shoulder arthroplasty to aid in patient selection

Background

A recent meta-analysis comparing inpatient and outpatient total shoulder arthroplasty (TSA) showed no statistically significant differences in complications, readmissions, revisions, and infections. However, there remains no research on the appropriate patient selection for outpatient TSA surgeries. This retrospective review seeks to aid surgeons in refining a safe patient selection algorithm by evaluating risk factors through a large database analysis of TSA surgeries.

Methods

Patients who underwent TSA between 2015 and 2020 were identified in the National Surgical Quality Improvement Program database. Patients with a hospital stay of 0 days were designated as outpatient procedures. Multivariate analyses were used to determine risk factors for 30-day readmission following outpatient TSA and whether risk factors remained significant following overnight hospital stay.

Results

A total of 2431 outpatient TSA patients were identified. The incidence of 30-day readmission was 1.8%. The majority of readmissions were due to pulmonary complications. The clinically significant risk factors for 30-day readmission were chronic steroid use (odds ratio [OR] 3.55, 95% confidence interval [CI] 1.34-9.43; P = .011), chronic obstructive pulmonary disease (COPD) (OR 3.11, 95% CI 1.16-8.34; P = .024), and current smoking status (OR 2.27, 95% CI 1.02-5.03; P = .045). After overnight hospital stay, chronic steroid use and current smoking status were not significant, but COPD remained significant.

Conclusion

Patients with chronic steroid use, COPD, or current smoking status are at increased risk for 30-day readmission. Inpatient hospital stay appears to benefit patients with chronic steroid use and current smoking status. Patients with COPD should be admitted for inpatient stay postoperatively but may still have high 30-day readmission rates following discharge.

Association between same-day discharge shoulder arthroplasty and risk of adverse events in patients with American Society of Anesthesiologists classification ≥3: a cohort study

BACKGROUND

Same-day discharge for shoulder arthroplasty (SA) is well-supported in the literature; however, most studies have focused on healthier patients. Indications for same-day discharge SA have expanded to include patients with more comorbidities, but safety of same-day discharge in this population remains unknown. We sought to compare outcomes following same-day discharge vs. inpatient SA in a cohort of patients considered higher risk for adverse events, defined as an American Society of Anesthesiologists (ASA) classification of ≥3.

METHODS

Data from Kaiser Permanente's SA registry were utilized to conduct a retrospective cohort study. All patients with an ASA classification of ≥3 who underwent primary elective anatomic or reverse SA in a hospital from 2018 to 2020 were included. The exposure of interest was in-hospital length of stay: same-day discharge vs. ≥1-night hospital inpatient stay. The likelihood of 90-day post-discharge events, including emergency department (ED) visit, readmission, cardiac complication, venous thromboembolism, and mortality, was evaluated using propensity score-weighted logistic regression with noninferiority testing using a margin of 1.10.

RESULTS

The cohort included a total of 1814 SA patients, of whom 1005 (55.4%) had same-day discharge. In propensity score-weighted models, same-day discharge was not inferior to an inpatient stay SA regarding 90-day readmission (odds ratio [OR] = 0.64, one-sided 95% upper bound [UB] = 0.89) and overall complications (OR = 0.67, 95% UB = 1.00). We lacked evidence in support of noninferiority for 90-day ED visit (OR = 0.96, 95% UB = 1.18), cardiac event (OR = 0.68, 95% UB = 1.11), or venous thromboembolism (OR = 0.91, 95% UB = 2.15). Infections, revisions for instability, and mortality were too rare to evaluate using regression analysis.

CONCLUSIONS

In a cohort of over 1800 patients with an ASA of ≥3, we found same-day discharge SA did not increase the likelihood of ED visits, readmissions, or complications compared with an inpatient stay, and same-day discharge was not inferior to an inpatient stay with regard to readmissions and overall complications. These findings suggest that it is possible to expand indications for same-day discharge SA in the hospital setting.

Prospective cohort study of same-day discharge shoulder arthroplasty in patients of 85 years and younger

Introduction

Shoulder arthroplasty is mostly performed as an inpatient procedure. Same-day discharge arthroplasty has shown positive results in hip and knee surgery. Primary objective of this study was to investigate whether a safe and satisfactory same-day discharge (SDD) can be predicted with a set of easy to use predefined criteria, without increasing complications and re-admissions.

Methods

This study was a prospective cohort study. Patient selection criteria were: <85 years old, ASA 1, 2, and mild ASA 3. Primary outcome variables were successful SDD, complications, re-admissions and patient satisfaction. Secondary outcomes were patient-reported outcome scores. The results are compared with the inpatient cohort.

Results

In total, 163 patients were treated for elective shoulder arthroplasty. Of which 51 patients were selected for same-day discharge arthroplasty. 94% of pre-planned same-day discharge arthroplasty patients were discharged on the day of surgery. In the same-day discharge group, there were no complications related to the early discharge and a 2% readmission rate as opposed to a 3% readmission rate in the inpatient group. Surgery related as well as medical complications did not differ between the same-day discharge and inpatient cohort.

Discussion

Same-day discharge shoulder arthroplasty is a safe and satisfying treatment option in selected patient groups.

The future of ambulatory surgery for geriatric patients

The elderly segment of the population is growing rapidly worldwide. Older patients comprise a disproportionate percentage of the surgical caseload. Physiological changes are inevitable with aging; some may impact a patient's response to anesthesia and surgery. Careful evaluation of an elderly patient preoperatively is vital to proper patient selection for ambulatory surgeries, particularly for complex and lengthy procedures. Cognitive issues, frailty, and geriatric syndromes make a patient vulnerable and sometimes unsuitable for certain ambulatory procedures. Preoperative planning and interventions may improve outcomes for the elderly patient undergoing ambulatory surgery.

Perioperative risk stratification tools for shoulder arthroplasty: a systematic review

BACKGROUND

Risk stratification tools are being increasingly utilized to guide patient selection for outpatient shoulder arthroplasty. The purpose of this study was to identify the existing calculators used to predict discharge disposition, postoperative complications, hospital readmissions, and patient candidacy for outpatient shoulder arthroplasty and to compare the specific components used to generate their prediction models.

METHODS

This review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis protocol. PubMed, Cochrane Library, Scopus, and OVID Medline were searched for studies that developed calculators used to determine patient candidacy for outpatient surgery or predict discharge disposition, the risk of postoperative complications, and hospital readmissions after anatomic or reverse total shoulder arthroplasty (TSA). Reviews, case reports, letters to the editor, and studies including hemiarthroplasty cases were excluded. Data extracted included authors, year of publication, study design, patient population, sample size, input variables, comorbidities, method of validation, and intended purpose. The pros and cons of each calculator as reported by the respective authors were evaluated.

RESULTS

Eleven publications met inclusion criteria. Three tools assessed patient candidacy for outpatient TSA, 3 tools evaluated the risk of 30- or 90-day hospital readmission and postoperative complications, and 5 tools predicted discharge destination. Four calculators validated previously constructed comorbidity indices used as risk predictors after shoulder arthroplasty, including the Charlson Comorbidity Index, Elixhauser Comorbidity Index, modified Frailty Index, and the Outpatient Arthroplasty Risk Assessment, while 7 developed newcalculators. Nine studies utilized multiple logistic regression to develop their calculators, while 1 study developed their algorithm based on previous literature and 1 used univariate analysis. Five tools were built using data from a single institution, 2 using data pooled from 2 institutions, and 4 from large national databases. All studies used preoperative data points in their algorithms with one tool additionally using intraoperative data points. The number of inputs ranged from 5 to 57 items. Four calculators assessed psychological comorbidities, 3 included inputs for substance use, and 1 calculator accounted for race.

CONCLUSION

The variation in perioperative risk calculators after TSA highlights the need for standardization and external validation of the existing tools. As the use of outpatient shoulder arthroplasty increases, these calculators may become outdated or require revision. Incorporation of socioeconomic and psychological measures into these calculators should be investigated.

Incidence and 30- and 90-day readmission rates after primary shoulder arthroplasty in the United States: an analysis using the National Readmissions Database

BACKGROUND

The field of shoulder arthroplasty has experienced a substantial increase in the number of procedures performed annually and a shift toward more common implantation of reverse shoulder arthroplasties (RSAs). Same-day discharge is perceived as beneficial for most patients as well as our health care system, and the number of shoulder procedures performed as same-day surgery has increased substantially. However, the potential benefits of same-day discharge after shoulder arthroplasty may be negatively influenced by unexpected readmissions. As such, an in-depth analysis of readmission rates after primary shoulder arthroplasty is particularly timely.

METHODS

The National Readmissions Database was queried for primary shoulder arthroplasty procedures performed in the United States between 2016 and 2018. National incidences were calculated, and indications, patient demographic characteristics, comorbidities, facility characteristics, and rates and causes of 30- and 90-day readmissions were determined for all procedures and compared between anatomic total shoulder arthroplasty (TSA), anatomic hemiarthroplasty (HA), and RSA.

RESULTS

During the study period, 336,672 primary shoulder arthroplasties were performed (37% TSAs, 57% RSAs, and 6% HAs). In 2018, national incidences per 100,000 inhabitants were 22.64 for RSA, 12.70 for TSA, and 1.50 for HA. The utilization of these procedures between 2016 and 2018 increased for RSA, decreased for HA, and remained constant for TSA, but these changes did not reach the level of statistical significance. The average all-cause 30-day readmission rates were 3.63%, 1.92%, and 3.81% for RSA, TSA, and HA, respectively, and the average all-cause 90-day readmission rates were 7.76%, 4.37%, and 9.18%, respectively. For both RSA and HA, the most common surgical diagnosis for 30-day and 90-day readmissions was dislocation (0.45% and 0.99%, respectively, for RSA and 0.21% and 0.67%, respectively, for HA). For TSA, the most common surgical diagnosis for 30-day readmission was infection (0.11%); however, this was surpassed by dislocation (0.28%) at 90 days.

CONCLUSION

RSA surpassed TSA as the most frequently performed shoulder arthroplasty procedure in the United States between 2016 and 2018. During this period, the 90-day readmission rate was not negligible, with dislocation and infection as the leading orthopedic causes of readmission.

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

BACKGROUND

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.

METHODS

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.

RESULTS

One hundred twenty-seven patients (47% male, 17% tobacco users, 18% diabetics) with a mean age 69 ± 9 years 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 3 months. There were 15 unplanned overnight hospital stays (11.8%) after the procedure. Within 90 days 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 70 years (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 70 years old (OR, 7.52 [95% CI, 1.26-45.45]; P = .027). No factors were predictive of 90-day hospital readmission or revision.

CONCLUSION

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 70 years 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.

Safety and short-term outcomes of anatomic vs. reverse total shoulder arthroplasty in an ambulatory surgery center

BACKGROUND

A scarcity of literature exists comparing outcomes of outpatient anatomic (aTSA) and reverse total shoulder arthroplasty (rTSA). This study was performed to compare early outcomes between the 2 procedures in a freestanding ambulatory surgery center (ASC) and to determine if the addition of preoperative interscalene nerve block (ISNB) with periarticular liposomal bupivacaine injection (PAI) in the postanesthesia care unit (PACU) would improve outcomes over PAI alone.

METHODS

Medical charts of all patients undergoing outpatient primary aTSA or rTSA at 2 ASCs from 2012 to 2020 were reviewed. A total of 198 patients were ultimately identified (117 aTSA and 81 rTSA) to make up this retrospective cohort study. Patient demographics, PACU outcomes, complications, readmissions, reoperations, calls to the office, and unplanned clinic visit rates were compared between procedures. PACU outcomes were compared between those receiving ISNB with PAI and those receiving PAI alone.

RESULTS

Patients undergoing rTSA were older (61.1 vs. 55.7 years, P < .001) and more likely to have American Society of Anesthesiologists (ASA) class 3 (51.9% vs. 41.0%, P = .050) compared to patients having aTSA. No patient required an overnight stay. Time in the PACU before discharge (89.1 vs. 95.6 minutes, P = .231) and pain scores at discharge (3.0 vs. 3.0, P = .815) were similar for aTSA and rTSA, respectively. One intraoperative complication occurred in the aTSA group (posterior humeral circumflex artery injury) and 1 in the rTSA group (calcar fracture) (P = .793). Ninety-day postoperative total complication (7.7% vs. 7.4%), shoulder-related complication (6.0% vs. 6.2%), medical-related complication (1.7% vs. 1.2%), admission (0.8% vs. 2.5%), reoperation (2.6% vs. 1.2%), and unplanned clinic visit (6.0% vs. 6.1%) rates were similar between aTSA and rTSA, respectively (P ≥ .361 for all comparisons). At 1 year, there were 8 reoperations and 15 complications in the aTSA group compared with 1 reoperation and 8 complications in the rTSA group (P = .091 and P = .818, respectively). Patients who had ISNB spent less time in PACU (75 vs. 97 minutes, P < .001), had less pain at discharge (0.2 vs. 3.9, P < .001), and consumed less oral morphine equivalents in the PACU (1.2 vs. 16.6 mg, P < .001).

CONCLUSION

Early postoperative outcomes and complication rates were similar between the 2 groups, and all patients were successfully discharged home the day of surgery. The addition of preoperative ISNB led to more efficient discharge from the ASC with less pain in the PACU.

Emergency Department Visits After Outpatient Spine Surgery

STUDY DESIGN

A retrospective study.

OBJECTIVE

This study sought to characterize the incidence and timing of postoperative emergency department (ED) visits after common outpatient spinal surgeries performed at ambulatory surgery centers (ASCs) and at hospital outpatient departments (HOPDs).

SUMMARY OF BACKGROUND DATA

Outpatient spine surgery has markedly grown in popularity over the past decade. The incidence of ED visits after outpatient spine surgery is not well established.

METHODS

This study was a retrospective analysis of a large commercial claims insurance database of patients 65 years old and below. Patients who underwent single-level anterior cervical discectomy and fusion, laminectomy, and microdiscectomy were identified. Incidence, timing, and diagnoses associated with ED visits within the postoperative global period (90 d) after surgery were assessed.

RESULTS

In total, 202,202 patients received outpatient spine surgery (19.1% in ASC vs. 80.9% in HOPD). Collectively, there were 22,198 ED visits during the 90-day postoperative period. Approximately 9.0% of patients had at least 1 ED visit, and the incidence varied by procedure: anterior cervical discectomy and fusion 9.9%, laminectomy 9.5%, and microdiscectomy 8.5% ( P <0.0001). After adjusting for age, sex, and comorbidity index, the odds of at least 1 ED visit were higher among patients who received surgery at HOPD versus ASC for all 3 procedures. The majority (56.1%) ED visits occurred during the first month postoperatively; 30.8% (n=6841) occurred within the first week postoperatively, and 10.7% (n=2370) occurred on the same day as the surgery. Postoperative pain was the most common reason for ED visits.

CONCLUSIONS

Among commercially insured patients who received outpatient spine surgery, the incidence of ED visits during the 90-day postoperative period was ~9%. Our results indicate opportunities for improved postoperative care planning after outpatient spinal surgery.

The transition to outpatient shoulder arthroplasty: a systematic review

BACKGROUND AND HYPOTHESIS

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.

METHODS

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.

RESULTS

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).

DISCUSSION AND CONCLUSION

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.

Comparison of outpatient vs. inpatient anatomic total shoulder arthroplasty: a propensity score–matched analysis of 20,035 procedures

Background

As the proportion of anatomic total shoulder arthroplasty (aTSA) operations performed at outpatient surgical sites continues to increase, it is important to evaluate the clinical implications of this evolution in care.

Methods

Patients who underwent TSA for glenohumeral osteoarthritis from 2007 to 2019 were identified in the American College of Surgeons National Surgical Quality Improvement Program registry. Demographic data and 30-day outcomes were collected, and patients were separated into inpatient and outpatient (defined as same day discharge) groups. To control for confounding variables, a propensity score–matching algorithm was utilized. Outcomes included 30-day adverse events, readmission, and operative time.

Results

A total of 20,035 patients who underwent aTSA between 2007 and 2019 were identified: 18,707 inpatient aTSAs and 1328 outpatient aTSAs. On matching, there were no significant differences in patient characteristics between inpatient and outpatient cohorts. Patients who underwent outpatient aTSA were less likely to experience a serious adverse event when compared with their matched inpatient aTSA counterparts (outpatient: 1.1% vs. inpatient: 2.1%, P = .03). Outpatient aTSA was associated with similar rates of all specific individual complications and readmissions (1.5% vs. 1.9%, P = .31).

Conclusion

When compared with a propensity score–matched cohort of inpatient counterparts, the present study found outpatient aTSA was associated with significantly reduced severe adverse events and similar readmission rates. These findings support the growing use of outpatient aTSA in appropriately selected patients.