Day case versus inpatient total shoulder arthroplasty: A retrospective cohort study and cost-effectiveness analysis

Abstract

Background: Day case total shoulder arthroplasty (TSA) is a novel approach, not widely practiced in Europe. We conducted a retrospective cohort study of patients comparing elective day case and inpatient TSAs in our UK centre. Aim: To evaluate the efficacy and cost-effectiveness of day case total shoulder arthroplasty (TSA) compared to standard inpatient total shoulder arthroplasty. Methods: All patients undergoing TSA between January 2017 and July 2018 were included. Outcome measures were: change in abduction and extension 3 months postoperatively; 30 day postoperative adverse events and re-admissions in day case and inpatient groups. We also conducted an economic evaluation of outpatient arthroplasty. Multivariate linear and logistic regression were used to adjust for demographic and operative covariates. Results: 59 patients were included, 18 day cases and 41 inpatients. There were no adverse events or re-admissions at 30 days postoperatively in either group. There were no significant differences in adjusted flexion (mean difference 16.4 degrees; 95% CI -17.6 to 50.5, p=0.337) or abduction (mean difference 13.2 degrees 95% CI; -18.4 to 44.9, p=0.405) postoperatively between groups. Median savings with outpatient arthroplasty were GBP 529 (IQR 247.33 to 789, p<0.0001). Conclusion: Day case TSA is a safe, effective procedure, with significant cost benefit. Wider use may be warranted in the UK and beyond, with potential for significant cost savings and improved efficiency. Core tip: In this article we show that day case total shoulder arthroplasty is a feasible, safe and effective alternative to inpatient admission for the same procedure, with an associated average cost saving of GBP 529.

Outpatient Total Shoulder Arthroplasty

“…The readmission rate after outpatient TSA was significantly lower than the readmission rate after inpatient TSA at 30 days (0.65% vs. 0.95%) and 90 days (2.03% vs. 2.87%) postoperatively (p , 0.05 for both). However, in all 4 studies, the outpatient cohort was significantly healthier (younger age, lower BMI, lower ASA class, and lower comorbidities) compared with the inpatient cohort 19,[22][23][24] (Fig. 3).…”

“…2). Six retrospective studies compared complication rates between inpatient and outpatient cohorts and found no significant differences 9,[18][19][20][21][22] . Four studies found that the complication rate was significantly lower in the outpatient cohort compared with the inpatient cohort [23][24][25][26] .…”

“…In fact, these studies showed that patients undergoing TSA in an inpatient setting were more likely to be older women with a higher body mass index (BMI), a higher ASA class, a history of smoking, diabetes, coronary artery disease (CAD), CHF, or chronic kidney disease (CKD) (p , 0.05 for all) 23,25,26 . Pooled statistical analysis was performed on comparative studies that reported 30-day and 90-day readmission rates after outpatient and inpatient TSA 19,[22][23][24] . The readmission rate after outpatient TSA was significantly lower than the readmission rate after inpatient TSA at 30 days (0.65% vs. 0.95%) and 90 days (2.03% vs. 2.87%) postoperatively (p , 0.05 for both).…”