Safety and Cost Effectiveness of Outpatient Total Shoulder Arthroplasty: A Systematic Review

Tyler E. Calkins, MD1 Zachary A. Mosher, MD1 Thomas W. Throckmorton, MD1 Tyler J. Brolin, MD1

1 University of Tennessee Health Science

Center-Campbell Clinic Department of Orthopaedic Surgery & Biomedical

Engineering, Memphis, Tennessee

Reprinted with permission:

Published in J Am Acad Orthop Surg 2022 Jan 15; 30(2):e233-e241.

https://journals.lww.com/jaaos/ Fulltext/2022/01150/Safety_and_Cost_ Effectiveness_of_Outpatient_Total.17.aspx

Corresponding Author:

Tyler J. Brolin, MD

1211 Union Avenue, Suite 510 Memphis, TN 38104 P: 901-759-3277 F: 901-759-3278 tbrolin@campbellclinic.com

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 Embase, 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 signifi cance 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 fi nding more readmissions after inpatient TSA. Complications were more common in inpatient TSA in fi ve 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 costeffective 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 profi les between outpatient and inpatient TSA.

Level of evidence

Level IV; systematic review.