Trends in outpatient versus inpatient total shoulder arthroplasty over time

Outcomes of ambulatory versus outpatient hospital-based surgical center shoulder arthroplasty: complications, readmissions, and charges

PURPOSE

The rising demand for primary total shoulder arthroplasty (TSA) has spurred interest in comparing the safety and cost-effectiveness of outpatient TSA in ambulatory surgical centers (ASCs) versus hospital-based centers (HSCs). This study evaluates ASCs and HSCs for medical complications, readmission rates, implant complications, and costs.

METHODS

This retrospective cohort study used the PearlDiver Mariner Database to identify patients undergoing primary TSA in ASCs or HSCs, assessing medical complications, readmissions, implant issues, and costs. ASC patients were matched in a 1:5 ratio to HSC patients by age, sex, region, and Elixhauser Comorbidity Index (ECI). Logistic regression analyzed the impact of ASC versus HSC settings on complications and readmissions, while Welch's t-tests compared costs. Statistical significance was determined by a P value less than or equal to 0.05.

RESULTS

ASCs showed lower odds of pulmonary embolism (OR = 0.69; P = 0.04), total medical complications (OR = 0.89; P = 0.01), prosthetic joint dislocation (OR = 0.43; P = 0.05), and total implant-related complications (OR = 0.85; P = 0.03), but a higher 90-day readmission rate (OR = 1.22; P < 0.01). ASCs also offered significant cost savings on the day of surgery ($4600 vs. $11,100; P < 0.01) and for 90-day total costs ($6600 vs. $13,500; P < 0.01) compared to HSCs.

CONCLUSION

Outpatient primary TSA in ASCs offers comparable safety with substantially lower costs than HSCs. Despite higher readmission rates, ASCs represent a viable, cost-effective alternative.

Toxic effects of local anesthetics on rat fibroblasts: An in-vitro study

BACKGROUND

Infusion catheters facilitate a controlled infusion of local anesthetic (LA) for pain control after surgery. However, their potential effects on healing fibroblasts are unspecified.

METHODS

Rat synovial fibroblasts were cultured in 12-well plates. Dilutions were prepared in a solution containing reduced-serum media and 0.9% sodium chloride in 1:1 concentration. Each well was treated with 500 μl of the appropriate LA dilution or normal saline for 15- or 30-min. LA dilutions included: 0.5% ropivacaine HCl, 0.2% ropivacaine HCl, 1% lidocaine HCl and epinephrine 1:100,000, 1% lidocaine HCl, 0.5% bupivacaine HCl and epinephrine 1:200,000, and 0.5% bupivacaine HCl. This was replicated three times. Dilution of each LA whereby 50% of the cells were unviable (Lethal dose 50 [LD50]) was analyzed.

RESULTS

LD50 was reached for lidocaine and bupivacaine, but not ropivacaine. Lidocaine 1% with epinephrine is toxic at 30-min at 1/4 and 1/2 sample dilutions. Bupivacaine 0.5% was found to be toxic at 30-min at 1/2 sample dilution. Bupivacaine 0.5% with epinephrine was found to be toxic at 15- and 30-min at 1/4 sample dilution. Lidocaine 1% was found to be toxic at 15- and 30-min at 1/2 sample dilution. Ropivacaine 0.2% and 0.5% remained below LD50 at all time-points and concentrations, with 0.2% demonstrating the least cell death.

CONCLUSIONS

Though pain pumps are generally efficacious, LAs may inhibit fibroblasts, including perineural fibroblast and endoneurial fibroblast-like cells, which may contribute to persistent nerve deficits, delayed neurogenic pain, and negatively impact healing. Should a continuous infusion be used, our data supports ropivacaine 0.2%.

LEVEL OF EVIDENCE

Basic Science Study; Animal model.

Outpatient versus inpatient shoulder arthroplasty outcomes using an updated patient-selection algorithm: minimum 2-year follow-up

BACKGROUND

Previous studies have demonstrated the safety and cost-effectiveness of outpatient total shoulder arthroplasty (TSA), with the majority of studies focusing on 90-day outcomes and complications. Patient selection algorithms have helped appropriately choose patients for an outpatient TSA setting. This study aimed to determine the outcomes of TSA between outpatient and inpatient cohorts with at least a 2-year follow-up.

METHODS

A retrospective review identified patients older than 18 years who underwent a TSA with a minimum of 2-year follow-up in either an inpatient or outpatient setting. Using a previously published outpatient TSA patient-selection algorithm, patients were allocated into three groups: outpatient, inpatient due to insurance requirements, and inpatient due to not meeting algorithm criteria. Outcomes evaluated included visual analog scale pain, American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation score, range of motion (ROM), strength, complications, readmissions, and reoperations. Analysis was performed between the outpatient and inpatient groups to demonstrate the safety and efficacy of outpatient TSA with midterm follow-up.

RESULTS

A total of 779 TSA were included in this study, allocated into the outpatient (N = 108), inpatient due to insurance (N = 349), and inpatient due to algorithm (N = 322). The average age between these groups was significantly different (59.4 ± 7.4, 66.5 ± 7.5, and 72.5 ± 8.7, respectively; P < .0001). All patient groups demonstrated significant improvements in preoperative to final patient-outcomes scores, ROM, and strength. Analysis between cohorts showed similar final follow-up outcome scores, ROM, and strength, with few significant differences that are likely not clinically different, regardless of surgical location, insurance status, or meeting patient-selection algorithm. Complications, reoperations, and readmissions between all three groups were not significantly different.

CONCLUSION

This study reaffirms prior short-term follow-up literature. Transitioning appropriate patients to outpatient TSA results in similar outcomes and complications compared to inpatient cohorts with midterm follow-up.

Regional variation from 2013 to 2021 in primary total shoulder arthroplasty utilization, reimbursement, and patient populations

BACKGROUND

Total shoulder arthroplasty (TSA), encompassing both anatomical and reverse TSA, has increased in popularity worldwide. The purpose of this study was to assess how TSA utilization, reimbursement, surgeon practices, and patient populations have evolved within the Medicare population from 2013 to 2021 at a national and regional level.

METHODS

The Medicare Physician and Other Practitioners dataset was queried for all episodes of primary TSA (CPT-23472), both anatomic and reverse, between years 2013 and 2021. TSA utilization was assessed as volume per 10,000 Medicare beneficiaries. Average inflation-adjusted reimbursement, physician practice styles, and patient demographics of each TSA surgeon were extracted each year. Data were stratified geographically based on US census classifications and rural-urban commuting codes. Kruskal-Wallis and multivariate regressions were utilized to determine differences between regions.

RESULTS

Between 2013 and 2021 TSA utilization increased by 121.8%, nationally. The increase was greatest in the Northeast (+147.2%) and least in the Midwest (+115.5%). Average TSA reimbursement declined by 8.8% nationally, with the least decline in the Northeast (6.4%) and the greatest decline in the Midwest (-11.9%). In 2021, the Midwest had the highest TSA utilization (18.1/10,000), while having the lowest average reimbursement ($1108.59; P < .001). The Northeast had the lowest utilization (11.5/10,000) and highest reimbursement ($1223.44; P < .001) in 2021. Nationally, the number of Medicare beneficiaries per surgeon performing shoulder arthroplasty declined by 5.9%, while the average number of TSAs per surgeon (+8.5%) and average number of billable services per beneficiary (+16.6%) both increased. Surgeons in the South performed the most services per beneficiary in 2021 (9.0; P < .001). The average comorbidity burden of patients was decreased by 4.8% between 2013 and 2021, with the West having the healthiest patients in 2021. Higher patient comorbidities were associated with lower physician reimbursement nationally (P < .001).

CONCLUSION

This study demonstrates that TSA utilization in the Medicare population has more than doubled between 2013 and 2021, while average inflation-adjusted reimbursement has declined by nearly 10%. The Midwest has the highest per-capita TSA utilization, while simultaneously having the lowest average reimbursement per TSA. Over time, TSA surgeons are seeing fewer and healthier beneficiaries but performing more services per beneficiary. Additionally, increased patient complexity may be associated with lower reimbursement. Together, these findings are concerning for long-term equitable access to care within shoulder surgery.

Definitional differences in "outpatient" surgery can influence study outcomes related to total shoulder arthroplasty

Background

Numerous studies have investigated the outcomes of outpatient total shoulder arthroplasty (TSA). However, some patients originally planned for outpatient surgery may unexpectedly require inpatient hospital stay, which can obscure the distinction of "outpatient" and "inpatient" cases. Ultimately, this inconsistent classification of "outpatient" surgery may influence study results. The objectives of this study were (1) to characterize the differences in definition of "outpatient" surgery (hospital-defined outpatient [HDO] vs. same-day discharge [SDD]), and (2) to study the effect of different definitions on 30-day outcomes following TSA.

Methods

The American College of Surgeons National Surgical Quality Improvement Program database was queried for patients who underwent TSA between 2011 and 2021. HDO cases were identified based on the National Surgical Quality Improvement Program inpatient or outpatient variable, and SDD cases were identified based on length of stay = 0. Demographic and clinical characteristics were compared between HDO and SDD cohorts. Propensity score was utilized to match each HDO and SDD case with one inpatient case without replacement. Two distinct sets of multivariate analyses, using Poisson regressions with robust error variance, were performed to calculate the risks of readmission, reoperation, morbidity, and complications for HDO and SDD.

Results

A total of 30,458 patients met the inclusion criteria, including 6711 HDO and 4490 SDD cases. 3501 out of the 6711 (52.2%) HDO patients required at least one night of inpatient hospital stay (length of stay >0). Between 2011 and 2021, the annual incidence of HDO TSA rose from 4.1% to 61.6% of all TSA cases, and the incidence of SDD TSA increased from 2.0% to 34.1% of all TSA cases. Compared to SDD, HDO was associated with female sex, higher body mass index, functional dependence, diabetes, chronic obstructive pulmonary disease, congestive heart failure, hypertension, American Society of Anesthesiologists ≥3, longer operation time, and nonhome discharge. After controlling for potential confounders, inpatient TSA was associated with increased risk of 30-day readmission and reoperation compared with HDO cases, while morbidity and individual complication rates were similar. However, compared with SDD patients, inpatient TSA was associated with higher rates of readmission, reoperation, morbidity, pneumonia, pulmonary embolism, myocardial infarction, and deep venous thrombosis.

Conclusion

Definitional differences in "outpatient" surgery can lead to significantly different study outcomes related to TSA. Future investigations on this topic should maintain consistency in the definition of "outpatient" surgery. Accurate data on the risk factors for adverse events after TSA are critical for appropriate patient selection and improving surgical outcomes.

Impact of insurance payer type (medicare vs. private) on the patient reported outcomes after shoulder arthroplasty

Background

This study's purpose is to determine if there is a difference in patient-reported outcome measures (PROMs) following shoulder arthroplasty (SA) based upon payer insurance type, with a secondary outcome of determining if any appreciable difference surpasses the minimal clinically important difference (MCID).

Methods

Subjects undergoing anatomic and reverse total shoulder arthroplasty were prospectively enrolled between March 2019 and March 2021. Subjects completed patient reported outcomes measurement information system upper extremity (P-UE), the American Shoulder and Elbow Surgeons score (ASES), and the simple shoulder test (SST) preoperatively and at 2 weeks, 6 weeks, 3 months, 6 months, and 12 months, postoperatively. Descriptive statistics of baseline patient characteristics and preoperative PROMs (ASES, SST, and P-UE) were compared between insurance types.

Results

143 patients were identified who met the inclusion criteria for this study. There were 98 patients within the Medicare cohort and 45 patients with private insurance. Patients in the Medicare cohort were older (mean age 70.5 vs. 61.3 years), with high proportion of smokers, diabetics, and reverse total shoulder arthroplasty compared to the private payor cohort. There were no significant differences between the two cohorts with respect to outcomes scores except for significantly better SST in the private insurance cohort (69.3 vs. 79.4, P = .02). No significant differences were noted for the achievement of MCID between cohorts [P-UE (P = 1.0), ASES (P = .25), and SST (0.52)] and pre-to-postoperative improvements for P-UE (P = .62), ASES (P = .4), or SST (0.66).

Conclusion

Our study demonstrates that, at a tertiary-level academic institution in a metropolitan city, payor type does not have significant impact on achieving MCID or pre-to-postoperative improvements in PROMs after SA.

Trends in inpatient versus outpatient upper extremity fracture surgery from 2008 to 2021 and their implications for equitable access: a retrospective cohort study

PURPOSE

The aim of this study is to describe trends in inpatient and outpatient upper extremity fracture surgery between 2008 and 2021, along with identifying patient factors (age, sex, race, socioeconomic status) associated with outpatient surgery.

METHODS

Retrospectively, 12,593 adult patients who underwent upper extremity fracture repair from 2008 to 2021 at one of five urban hospitals in the Northeastern USA were identified. Using Distressed Communities Index (DCI), patients were divided into five quintiles based on their level of socioeconomic distress. Multivariable logistic regression was performed on patients from 2008 to 2019 to identify independent factors associated with outpatient management.

RESULTS

From 2008 to 2019, outpatient procedures saw an average increase of 31%. The largest increases in the outpatient management were seen in humerus (132%) and forearm fractures (127%). Carpal and hand surgeries had the lowest percent increase of 8.1%. Clavicle and wrist fractures were independently associated with outpatient management. Older age, male sex, higher Elixhauser comorbidity index, DCI scores in the 4th or 5th quintile, and fractures of the scapula, humerus, elbow, and forearm were associated with inpatient management. During the onset of the COVID-19 pandemic, there was a decrease in outpatient procedures.

CONCLUSION

There is a shift toward outpatient surgical management of upper extremity fractures from 2008 to 2021. Application of our findings can serve as an institutional guide to allocate patients to appropriate surgical settings. Moreover, physicians and institutions should be aware of the potential socioeconomic disparities and implement plans to allow for equal access to care.

Predictors of inpatient mortality following reverse shoulder arthroplasty

INTRODUCTION

The number of reverse shoulder arthroplasties (RSA) performed each year is growing rapidly, especially in elderly patients and with expanded indications including geriatric proximal humerus fractures. As the elderly population grows and the number of RSA's annually continues to rise, there will be a proportionate number of adverse events and mortality. However, the rate of early mortality has consistently shown to be less than 1%, so a large-scale analysis of possible risk factors for post-operative mortality is warranted.

METHODS

A retrospective multivariate analysis of 59,915 patients from the National Inpatient Sample database between 2016 and 2019 was performed. Patients who underwent RSA were identified based on ICD-10 code. Patients were divided into two groups, early mortality and no mortality. Early mortality was defined as those who died within the same admission. Patient demographics and medical comorbidities were evaluated. Hospital admission status was classified as elective or non-elective. Odds ratios for predictive variables were measured as a ratio of incidence between the early mortality and no mortality groups.

RESULTS

The overall incidence of inpatient mortality was 0.07%. The incidence of mortality for elective admissions was 0.04% and for non-elective admissions was 0.34%. On univariate analysis, age greater than 75 years (p < 0.001), octogenarians (p < 0.001), nonagenarians (p < 0.001), and non-elective admission (p < 0.001) were associated with early mortality following RSA. Upon multivariate analysis, age greater than 75 years old had 4 times the odds of early mortality following RSA (OR 4.20; 95%CI (1.67, 10.60); p < 0.001) while non-elective admission had about 5 times the odds (OR 5.38; 95%CI (2.75, 10.53); p < 0.001).

DISCUSSION

Age greater than 75 years old has 4-fold higher odds and non-elective admission has 5-fold higher odds of early mortality following RSA. Appropriate pre-operative counseling should be performed with elderly patients and those undergoing non-elective indications for RSA.

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.

Trends and outcomes of outpatient total shoulder arthroplasty after its removal from CMS's inpatient-only list

BACKGROUND

In January 2021, the US Medicare program approved reimbursement of outpatient total shoulder arthroplasties (TSA), including anatomic and reverse TSAs. It remains unclear whether shifting TSAs from the inpatient to outpatient setting has affected clinical outcomes. Herein, we describe the rate of outpatient TSA growth and compare inpatient and outpatient TSA complications, readmissions, and mortality.

METHODS

Medicare fee-for-service claims for 2019-2022Q1 were analyzed to identify the trends in outpatient TSAs and to compare 90-day postoperative complications, all-cause hospital readmissions, and mortality between outpatients and inpatients. Outpatient cases were defined as those discharged on the same day of the surgery. To reduce the COVID-19 pandemic's impact and selection bias, we excluded 2020Q2-Q4 data and used propensity scores to match 2021-2022Q1 outpatients with inpatients from the same period (the primary analysis) and from 2019-2020Q1 (the secondary analysis), respectively. We performed both propensity score-matched and -weighted multivariate analyses to compare outcomes between the two groups. Covariates included sociodemographics, preoperative diagnosis, comorbid conditions, the Hierarchical Condition Category risk score, prior year hospital/skilled nursing home admissions, annual surgeon volume, and hospital characteristics.

RESULTS

Nationally, the proportion of outpatient TSAs increased from 3% (619) in 2019Q1 to 22% (3456) in 2021Q1 and 38% (6778) in 2022Q1. A total of 55,166 cases were identified for the primary analysis (14,540 outpatients and 40,576 inpatients). Overall, glenohumeral osteoarthritis was the most common indication for surgery (70.8%), followed by rotator cuff pathology (14.6%). The unadjusted rates of complications (1.3 vs 2.4%, P < .001), readmissions (3.7 vs 6.1%, P < .001), and mortality (0.2 vs 0.4%, P = .024) were significantly lower among outpatient TSAs than inpatient TSAs. Using 1:1 nearest matching, 12,703 patient pairs were identified. Propensity score-matched multivariate analyses showed similar rates of postoperative complications, hospital readmissions, and mortality between outpatients and inpatients. Propensity score-weighted multivariate analyses resulted in similar conclusions. The secondary analysis showed a lower hospital readmission rate in outpatients (odds ratio: 0.8, P < .001).

CONCLUSIONS

There has been accelerated growth in outpatient TSAs since 2019. Outpatient and inpatient TSAs have similar rates of postoperative complication, hospital readmission, and mortality.

Inpatient or outpatient total elbow arthroplasty: a comparison of patient populations and 30-day surgical outcomes from the American College of Surgeons National Surgical Quality Improvement Program

BACKGROUND

Total elbow arthroplasty (TEA) is uncommon, but growing in incidence. Traditionally an inpatient operation, a growing number are performed outpatient, consistent with general trends in orthopedic surgery. The aim of this study was to compare TEA outcomes between inpatient and outpatient surgical settings. Secondarily, we sought to identify patient characteristics that predict the operative setting.

METHODS

Patient data were collected from the American College of Surgeons National Quality Improvement Program. Preoperative variables, including patient demographics and comorbidities, were recorded, and baseline differences were assessed via multivariate regression to predict operative setting. Multivariate regression was also used to compare postoperative complications within 30 days.

RESULTS

A total of 468 patients, 303 inpatient and 165 outpatient procedures, were identified for inclusion. Hypoalbuminemia (odds ratio [OR], 2.5; P=0.029), history of chronic obstructive pulmonary disorder or pneumonia (OR, 2.4; P=0.029), and diabetes mellitus (OR, 2.5; P=0.001) were significantly associated with inpatient TEA, as were greater odds of any complication (OR, 4.1; P<0.001) or adverse discharge (OR, 4.5; P<0.001) and decreased odds of reoperation (OR, 0.4; P=0.037).

CONCLUSIONS

Patients undergoing inpatient TEA are generally more comorbid, and inpatient surgery is associated with greater odds of complications and adverse discharge. However, we found higher rates of reoperation in outpatient TEA. Our findings suggest outpatient TEA is safe, although patients with a higher comorbidity burden may require inpatient surgery. Level of evidence: III.

Smoking is an independent risk factor for complications in outpatient total shoulder arthroplasty

Background

Smoking is a major public health concern and an important risk factor to consider during preoperative planning. Smoking has previously been reported as the single most important risk factor for developing postoperative complications after elective orthopedic surgery. However, there is limited literature regarding the postoperative complications associated with smoking following outpatient total shoulder arthroplasty (TSA). The purpose of this study was to investigate the association between smoking status and early postoperative complications following outpatient TSA using a large national database.

Methods

We queried the American College of Surgeons National Surgical Quality Improvement Program database for all patients who underwent TSA between 2015 and 2020. Smoking status in National Surgical Quality Improvement Program is defined as any episode of smoking with 12 months prior to surgery. Bivariate logistic regression was used to identify patient demographics, comorbidities, and complications significantly associated with current or recent smoking status in patients who underwent TSA with a length of stay (LOS) of 0. Multivariate logistic regression, adjusted for all significantly associated patient demographics and comorbidities, was used to identify associations between current or recent smokers and 30-day postoperative complications.

Results

22,817 patients were included in the analysis, 2367 (10.4%) were current or recent smokers and 20,450 (89.6%) were nonsmokers. These patients were further stratified based on LOS: 2428 (10.6%) patients had a LOS of 0 days, 15,267 (66.9%) patients had a LOS of 1 day, and 5122 (22.4%) patients had a LOS of 2 days. Within the outpatient cohort (LOS = 0), 202 (8.3%) patients were current or recent smokers and 2226 (91.7%) were nonsmokers. Multivariate logistic regression identified current or recent smoking status to be independently associated with higher rates of myocardial infarction (odds ratio [OR] 9.80, 95% confidence interval [CI] 1.48-64.96; P = .018), deep vein thrombosis (OR 20.05, 95% CI 1.63-247.38; P = .019), and readmission (OR 2.82, 95% CI 1.19-6.67; P = .018) following outpatient TSA. Readmission was most often due to pulmonary complication (n = 10, 22.7%).

Conclusion

Current or recent smoking status is independently associated with higher rates of myocardial infarction, deep vein thrombosis, and readmission following TSA performed in the outpatient setting. Current or recent smokers may benefit from an inpatient setting of minimum 2 nights. As outpatient TSA becomes increasingly popular, refining proper patient selection criteria is imperative to optimizing postoperative outcomes.

Costs of shoulder and elbow procedures are significantly reduced in ambulatory surgery centers compared to hospital outpatient departments

BACKGROUND

Recent literature has shown the advantages of outpatient surgery for many shoulder and elbow procedures, including cost savings with equivalent safety in appropriately selected patients. Two common settings for outpatient surgeries are ambulatory surgery centers (ASCs), which function as independent financial and administrative entities, or hospital outpatient departments (HOPDs), which are owned and operated by hospital systems. The purpose of this study was to compare shoulder and elbow surgery costs between ASCs and HOPDs.

METHODS

Publicly available data from 2022 provided by the Centers for Medicare & Medicaid Services (CMS) was accessed via the Medicare Procedure Price Lookup Tool. Current Procedural Terminology (CPT) codes were used to identify shoulder and elbow procedures approved for the outpatient setting by CMS. Procedures were grouped into arthroscopy, fracture, or miscellaneous. Total costs, facility fees, Medicare payments, patient payment (costs not covered by Medicare), and surgeon's fees were extracted. Descriptive statistics were used to calculate means and standard deviations. Cost differences were analyzed using Mann-Whitney U tests.

RESULTS

Fifty-seven CPT codes were identified. Arthroscopy procedures (n = 16) at ASCs had significantly lower total costs ($2667 ± $989 vs. $4899 ± $1917; P = .009), facility fees ($1974 ± $819 vs. $4206 ± $1753; P = .008), Medicare payments ($2133 ± $791 vs. $3919 ± $1534; P = .009), and patient payments ($533 ± $198 vs. $979 ± $383; P = .009) compared with HOPDs. Fracture procedures (n = 10) at ASCs had lower total costs ($7680 ± $3123 vs. $11,335 ± $3830; P = .049), facility fees ($6851 ± $3033 vs. $10,507 ± $3733; P = .047), and Medicare payments ($6143 ± $2499 vs. $9724 ± $3676; P = .049) compared with HOPDs, although patient payments were not significantly different ($1535 ± $625 vs. $1610 ± $160; P = .449). Miscellaneous procedures (n = 31) at ASCs had lower total costs ($4202 ± $2234 vs. $6985 ± $2917; P < .001), facility fees ($3348 ± $2059 vs. $6132 ± $2736; P < .001), Medicare payments ($3361 ± $1787 vs. $5675 ± $2635; P < .001), and patient payments ($840 ± $447 vs. $1309 ± $350; P < .001) compared with HOPDs. The combined cohort (n = 57) at ASCs had lower total costs ($4381 ± $2703 vs. $7163 ± $3534; P < .001), facility fees ($3577 ± $2570 vs. $6539.1 ± $3391; P < .001), Medicare payments ($3504 ± $2162 vs. $5892 ± $3206; P < .001), and patient payments ($875 ± $540 vs. $1269 ± $393; P < .001) compared with HOPDs.

CONCLUSION

Shoulder and elbow procedures performed at HOPDs for Medicare recipients were found to have average total cost increase of 164% compared with those performed at ASCs (184% savings for arthroscopy, 148% for fracture, and 166% for miscellaneous). ASC use conferred lower facility fees, patient payments, and Medicare payments. Policy efforts to incentivize migration of surgeries to ASCs may translate into substantial health care cost savings.

Short-Term Outcomes and Long-Term Implant Survival After Inpatient Surgical Management of Geriatric Proximal Humerus Fractures

Introduction

The most common surgical options for geriatric proximal humerus fractures are open reduction and internal fixation (ORIF), hemiarthroplasty (HA), and reverse total shoulder arthroplasty. We used a longitudinal inpatient discharge database to determine the cumulative incidence of conversion to arthroplasty after ORIF of geriatric proximal humerus fractures. The rates of short-term complications and all-cause reoperation were also compared.

Patients and Methods

All patients 65 or older who sustained a proximal humerus fracture and underwent either ORIF, HA, or shoulder arthroplasty (SA) as an inpatient from 2000 through 2017 were identified. Survival analysis was performed with ORIF conversion to arthroplasty and all-cause reoperation as the endpoints of interest. Rates of 30-day readmission and short-term complications were compared. Trends in procedure choice and outcomes over the study period were analyzed.

Results

A total of 27 102 geriatric patients that underwent inpatient surgical management of proximal humerus fractures were identified. Among geriatric patients undergoing ORIF, the cumulative incidence of conversion to arthroplasty within 10 years was 8.2%. The 10-year cumulative incidence of all-cause reoperation was 12.1% for ORIF patients and less than 4% for both HA and SA patients. Female sex was associated with increased risk of ORIF conversion and younger age was associated with higher all-cause reoperation. ORIF was associated with higher 30-day readmission and short-term complication rates. Over the study period, the proportion of patients treated with ORIF or SA increased while the proportion of patients treated with HA decreased. Short-term complication rates were similar between arthroplasty and ORIF patients in the later cohort (2015-2017).

Conclusion

The 10-year cumulative incidence of conversion to arthroplasty for geriatric patients undergoing proximal humerus ORIF as an inpatient was found to be 8.2%. All-cause reoperations, short-term complications, and 30-day readmissions were all significantly lower among patients undergoing arthroplasty, but the difference in complication rate between arthroplasty and ORIF was attenuated in more recent years. Younger age was a risk factor for reoperation and female sex was associated with increased risk of requiring conversion to arthroplasty after ORIF.

Risk Factors for 30-Day Unplanned Re-Operation in Pediatric Upper Extremity Surgery: A National Surgical Quality Improvement Program (NSQIP)-Pediatric Analysis

Introduction The unplanned re-operation rate has been used as one marker of procedure quality in numerous surgical sub-fields. The purpose of this study was to determine independent risk factors for unplanned re-operations within 30 days following pediatric upper extremity surgery. Methods Pediatric patients who had a primary upper extremity procedure from 2012 to 2019 were identified in the National Surgical Quality Improvement Program-Pediatric database. The procedures included percutaneous fixation of supracondylar humerus fractures, open treatment of humeral condylar fractures, tendon sheath incision, repair of syndactyly, and reconstruction of polydactyly. Patients were categorized by those who had unplanned return to the operating room within 30 days and patients who did not. Patient demographics, clinical characteristics, and medical co-morbidities were evaluated for their association with re-operation using bivariate and multivariate analysis. Results A total of 27,536 pediatric patients underwent primary upper extremity surgeries; of these, 290 (1.1%) required an unplanned re-operation. After controlling for potential confounding variables on multivariable regression analysis, American Society of Anesthesiologists (ASA) class III-V (OR 15.89; p<0.001), inpatient procedure (OR 1.29; p=0.044), emergent/urgent triage (OR 3.75; p<0.001), longer operative time (OR 1.01; p<0.001), and prolonged hospital stay (OR 1.01; p=0.010) were independent predictors for re-operation. Conclusion This study demonstrates that the national rate of 30-day unplanned re-operation in pediatric upper extremity surgeries is low overall. The greatest risk factors for unplanned re-operation were ASA class III-V, inpatient setting, emergent/urgent triage, longer operative time, and prolonged hospital stay. This knowledge can help further improve patient outcomes through risk stratification and preoperative planning.

Seasonality in General Surgery Hospitalizations and Procedures in the US: Workflow Implications

INTRODUCTION

Seasonality has been studied in select conditions treated by surgeons and internists, but is not well understood regarding overall procedural volume in general surgery. Furthermore, much of the literature is limited due to lack of use of seasonal-trend-decomposition analyses.

METHODS

All admissions with general surgery procedures were pooled from NIS 2002-2014, monthly hospitalization rates calculated, and seasonal-trend decomposition performed.

RESULTS

Emergent admissions, accounting for 9% of the average annual incidence, had more prominent seasonality than elective admissions. Inpatient surgical-procedural volume remained relatively stable throughout the year and decreased only in the third quarter. Procedures for acute intra-abdominal conditions and traumas peaked in summer months, while endoscopies, tracheostomies and gastrostomies peaked in winter months.

CONCLUSIONS

Many surgical pathologies and corresponding general-surgery procedures obey circannual patterns. Surgical workforce remains in high demand throughout the year except for fall and winter holidays. Understanding seasonal variation in such demand may be important for staffing and resource planning.

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.

Patient outcomes after revision total shoulder arthroplasty in an inpatient vs. outpatient setting

BACKGROUND

Total shoulder arthroplasty (TSA) is becoming an increasingly common surgical procedure for numerous shoulder conditions. The incidence of revision TSA is increasing because of the increase in primary TSA and the increased utilization of TSA in younger patients. Conducting revision TSA as an outpatient procedure would be beneficial in limiting expenditure and resource allocation but must show a similar complication profile compared to inpatient revision TSA in order to justify its clinical value. The purpose of this study is to compare the outcomes of outpatient revision TSA to inpatient revision TSA and outpatient primary TSA.

METHODS

The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database was queried from 2010-2019 to identify all patients who underwent revision TSA (n = 1456) in either an inpatient or outpatient setting, as well as patients who underwent primary TSA in an outpatient setting (n = 2630). Relevant demographic characteristics were compared between the outpatient revision group and both the inpatient revision and outpatient primary groups. Postoperative complications, readmission, and reoperation rates were also compared between the groups.

RESULTS

Patients undergoing inpatient revision TSA exhibited increased rates of preoperative hypertension (P = .013) and had increased prevalence of severe American Society of Anesthesiologists classification (P = .021) compared to patients undergoing outpatient revision TSA. Patients undergoing outpatient revision TSA were significantly more likely to experience complications (P < .001), have longer surgical times (P < .001), and undergo readmission (P = .006) and reoperation (P = .049) compared to patients undergoing outpatient primary TSA. There was no significant increase in rates of overall complication, readmission, or reoperation between patients undergoing revision TSA in an outpatient vs. an inpatient setting.

CONCLUSION

Outpatient revision TSA has higher complication rates, readmission, and reoperation rates compared to outpatient primary TSA, similar to previous findings when comparing revision and primary TSA done as an inpatient. However, there was no increased risk of complications, readmission, or reoperation for outpatient revision TSA compared to inpatient revision TSA. Outpatient revision TSA should be considered by orthopedic surgeons in patients who are medically healthy to undergo the procedure as an outpatient surgery.

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.