Inpatient vs Outpatient Shoulder Arthroplasty

The study entitled “Is outpatient shoulder arthroplasty safe in patients ≥65 years? A comparison of readmissions and complications in inpatient and outpatient settings” follows 145 patients undergoing shoulder replacement surgery at a single institution by the same surgeon; 47 of these patients were preselected for outpatient surgery.

Criteria for selection for inpatient surgery were a history of high-risk cardiovascular disease, the need for cardiac or pulmonary medical clearance, or patient preference. Not surprisingly, this inpatient cohort was disproportionately older (average age of 75.5 years vs 70.5 in the outpatient group), sicker (based on ASA score), and had a higher proportion undergoing reverse shoulder arthroplasty.

Discussion

Consistent with my observations and the reports from a multitude of sources in recent shoulder arthroplasty literature, there were no significant differences in post-operative complications or ED returns between inpatient and outpatient groups. This study, among others, provides further reason to reevaluate shoulder arthroplasty as an inpatient-only procedure.

Looking critically at the data in this study, the complication rates were not statistically significantly different between the inpatient and outpatient cohorts. There were correlations with higher age and ASA scores on complication rates in both groups, with age being the most important risk factor with a 14% higher year-over-year increase in surgical complication rates.

Notably, many of the surgical complications included post-operative instability in the setting of reverse shoulder arthroplasty (RSA), rotator cuff dysfunction/lesser tuberosity osteotomy failure in the setting of anatomic replacement, and acromial stress reaction after RSA. Many of these complications are potentially modifiable and not necessarily dependent on patient factors. It is unclear whether subscapularis repair was performed with RSAs (which can impart stability), and which design/manufacturer was utilized (which can affect stability and the appearance of acromial stress reaction).

This shift has not only preserved healthcare resources, such as bed availability and personal protective equipment, it has also been preferred by patients for improved satisfaction and lessened risk of viral exposure during hospital admission.

Importantly, as noted above, there were no differences in rates of patients returning to the ED in either cohort. Consistent with what would be expected with appropriate preoperative risk stratification, inpatient arthroplasties had a higher rate of readmission (P=0.034) to the hospital, which is largely a function of medical factors that are more frequent and severe in older patients with higher ASA scores.

The COVID-19 pandemic has undoubtedly generated a shift to outpatient surgery. This shift has not only preserved healthcare resources, such as bed availability and personal protective equipment, it has also been preferred by patients for improved satisfaction and lessened risk of viral exposure during hospital admission. This study is consistent with a great number of sources suggesting that shoulder replacement can continue to be offered safely in the outpatient setting with an eye to preserving healthcare resources and optimizing access to treatment for appropriately selected patients during a pandemic.

The one-size-fits-all “inpatient only” status for shoulder replacement assigned by Medicare requires reevaluation as many of these older patients are, in fact, safe candidates for surgery at hospital outpatient departments and ambulatory surgery centers.

In summary, not all patients ≥65 years of age require inpatient surgery; and although many of these patients do, the cohort undergoing outpatient surgery can be done safely with a very low rate of complications, ED returns, and readmissions.  This is further evidence that the decision-making on where to have surgery is best done by the physician in consultation with the patient and the family.

The one-size-fits-all “inpatient only” status for shoulder replacement assigned by Medicare requires reevaluation as many of these older patients are, in fact, safe candidates for surgery at hospital outpatient departments and ambulatory surgery centers. By Medicare not lifting this “inpatient only” status, many of these patients may continue to have limits on access to inpatient care with COVID restrictions and concerns about exposure to the SARS-CoV-2 virus.

Conclusion

In my own practice, I use many of the risk factors identified in this study as part of my preoperative risk stratification (age, history of cardiopulmonary disease, requirement for specialist clearance) when counseling potential shoulder replacement patients on the appropriate venue.

The pandemic has given us an accelerated learning experience on patient selection for outpatient surgery. We can use this experience, coupled with the results of studies like this one, to provide the best care for our patients in the most appropriate location–whether hospital inpatient facility, hospital outpatient department, or ambulatory surgery center.

 

Thomas Obermeyer, MD, is a board-certified and fellowship-trained orthopaedic surgeon in Illinois, specializing in shoulder and elbow reconstruction and sports injuries. Dr. Obermeyer received his medical degree from Albany Medical College and completed his residency at Loyola University Medical Center in Chicago. He went on to complete a fellowship in shoulder and elbow at Mount Sinai Medical Center in New York City. Dr. Obermeyer is also an award-winning researcher and published author.

For additional content on outpatient surgery, read our blog post titled Performing Total Shoulder Arthroplasty in an Outpatient Setting. To access our library of resources for tools and techniques that can improve patient outcomes, visit the landing page of our Innovations Blog.