Outpatient Shoulder Arthroplasty Is Safe, Effective and Cheaper Than Inpatient Surgery

Given continued pressure on health care organizations to reduce costs, the move to outpatient shoulder arthroplasty (OSA) has been increasing dramatically. Outpatient total hip and total knee arthroplasty are now established to have a favorable adverse event profile and provide substantial savings, but OSA is newer, and less is known.

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Evan A. O'Donnell, MD, sports medicine and shoulder orthopedic surgeon, Jon J.P. Warner, MD, chief of the Shoulder Service and co-director of the Harvard Shoulder & Elbow Fellowship in the Department of Orthopaedics at Massachusetts General Hospital, and colleagues recently systematically reviewed the literature about OSA. In JBJS Reviews, they conclude that, with proper patient selection, OSA compares well with inpatient surgery in terms of safety, patient-reported outcomes and satisfaction, readmission rates and cost.

Summary of Evidence

The team searched PubMed, Embase and the Cumulative Index to Nursing and Allied Health Literature from inception to May 14, 2020. They included 23 articles in the final analysis:

• 16 diagnostic and therapeutic studies (eight with Level III evidence, most conducted in large administrative or insurance databases; eight Level IV)
• Three economic analyses
• Three review articles
• One survey of expert opinion (members of the American Shoulder and Elbow Surgeons [ASES])

Patient Selection

Reports on eight studies mentioned selection criteria, although four gave vague criteria. Collectively, the articles mentioned:

• Inclusion criteria—age <70, American Society of Anesthesiologists class I or II, BMI <35 kg/m², local residence, patient preference, payer approval and social/home support
• Exclusion criteria—anemia (relative contraindication), chronic obstructive pulmonary disease, chronic opioid use, congestive heart failure, coronary artery disease, diabetes, dyspnea, hypertension, obstructive sleep apnea, stroke and venous thromboembolism

There was no agreement across studies, but social/home support, age <70, BMI <35 and patient preference were most commonly cited.

Complications and Readmissions

11 studies reported on complications of a total of 6,873 OSA procedures. Even the most prevalent complications occurred in ≤2% of cases (weighted averages):

• Most prevalent medical complications—respiratory failure (2.1%), stroke (2.1%), urinary tract infection (1.9%) and deep vein thrombosis (1.3%)
• Most prevalent surgical complications—need for revision (1.8%), postoperative stiffness (1.3%), blood transfusion (1.0%) and superficial or deep surgical site infection (0.8%)

Readmission rates in the 11 studies (weighted averages) were:

• 1.4% at 30 days
• 3.3% at 90 days

In eight studies that made direct comparisons, rates of medical complications were equivalent or lower in OSA compared with an inpatient cohort. Rates of all surgical complications were also equivalent or lower in the outpatient cohort, with the exception that one study showed a higher risk of postoperative infection.

All eight studies showed lower or equivalent readmission rates with OSA versus inpatient surgery.

Patient-reported Outcomes

Two studies evaluated joint-specific metrics, the ASES and Single Assessment Numeric Evaluation (SANE) scores. Both detected clinically important and statistically significant improvements in these metrics in the short term (three months) and intermediate term (two years).

One of the studies compared postoperative ASES scores in outpatient and inpatient cohorts and found no significant difference.

Both studies also showed significant short- and intermediate-term improvement in pain scores. Three additional studies determined perioperative pain control was adequate.

Patient Satisfaction

Three studies that assessed subjective patient experience showed >90% of patients had good or excellent experiences, preferred outpatient arthroplasty to inpatient arthroplasty for future surgery and were very satisfied.

Cost

Three studies compared the cost of OSA and inpatient shoulder arthroplasty and showed significant cost reduction with OSA.

Conclusion

Critical appraisal of the articles selected indicated the possibility of a biased study design. Definitive conclusions about OSA await studies that provide level I evidence.

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