The safety of outpatient total shoulder arthroplasty: a systematic review and meta-analysis

Abstract

Purpose To meet the increasing demands of total shoulder arthroplasty (TSA) while reducing its financial burden, there has been a shift toward outpatient surgery. This systematic review and meta-analysis aimed to evaluate the safety of outpatient TSA. Methods The primary objective was to compare re-admission rates and postoperative complications in outpatient versus inpatient TSA. The secondary objectives were functional outcomes and costs. PubMed, Google Scholar, and Web of Science were searched until March 28, 2020. The inclusion criteria were studies reporting at least complications or readmission rates within a period of 30 days or more. Results Ten level III retrospective studies were included with 7637 (3.8%) and 192,025 (96.2%) patients underwent outpatient and inpatient TSA, respectively. Outpatient TSA had relatively younger and healthier patients. There were no differences between outpatient and inpatient arthroplasty for 30- and 90-day readmissions. Furthermore, unadjusted comparisons demonstrated significantly less total and major surgical complications, less total, major, and minor medical complications in favour of outpatient TSA. However, subgroup analyses demonstrated that there were no significant differences in all complication if the studies had matched controls and regardless of data source (database or nondatabase studies). The revision rates were similar between both groups at a 12–24 months follow-up. Two studies reported a significant reduction in costs in favour of outpatient TSA. Conclusion This study highlights that outpatient TSA could be a safe and effective alternative to inpatient TSA in appropriately selected patients. It was evident that outpatient TSA does not lead to increased readmissions, complications, or revision rates. A potential additional benefit of outpatient TSA was cost reduction.

Comparison of outpatient vs. inpatient anatomic total shoulder arthroplasty: a propensity score–matched analysis of 20,035 procedures

“…Our findings are consistent with several other studies supporting the safety of outpatient aTSA. In a systematic review and meta-analysis of outcomes of inpatient and outpatient aTSA, Ahmed et al 1 found no significant differences across all complications between groups, which remained consistent when analyzing database 6 , 7 , 13 , 22 , 24 , 28 and nondatabase 12 , 17 , 27 studies as part of a subgroup analysis. Although these studies were unable to find a significant difference across all complications, the present study detected a significantly lower rate of severe adverse events in the outpatient cohort.…”

“…Several institutional studies comparing outpatient and inpatient aTSA procedures have reported similar complication and readmission rates between groups, supporting the notion that outpatient aTSA procedures can be safe and cost-saving in appropriately selected patients. 1 , 5 , 7 , 10 , 12 , 14 , 17 , 24 , 27 , 38 For example, in single-surgeon centers, Borakati et al 10 and Brolin et al 12 found similar rates of total complications for inpatient and outpatient aTSA procedures. However, these studies may have been underpowered to detect a difference in outcomes and limited to specialized academic centers.…”

“… 16 , 29 , 37 To mitigate rising costs and exercise value-based health care, providers have recently shifted aTSA operations from the inpatient to outpatient setting in select patient populations. 18 , 31 As the proportion of aTSA operations performed at outpatient surgical sites continues to increase, 1 , 15 it is important to appraise the clinical implications of this evolution in care.…”

Trends in outpatient versus inpatient total shoulder arthroplasty over time

“… 7 , 10 , 18 Indeed, a recent meta-analysis found no significant differences between matched inpatient and outpatient TSA groups in regard to medical complications, surgical complications, or hospital readmissions. 1 Compared with the aforementioned database studies, the present study benefits from the addition of more recent ACS-NSQIP data to include a greater number of outpatient procedures. We were also able to observe trends over time by dividing patients between an early and late cohort.…”

“… 11 , 26 These developments have spurred interest in performing TSA in the outpatient setting, which has been shown to be safe and effective. 1 Approximately 2%-3% of TSA procedures were performed outpatient in the early 2010s, and that proportion has steadily increased, with the number of TSAs performed in ambulatory surgery centers doubling over a 5-year span. 3 , 9 , 23 Leroux et al found high levels of patient satisfaction with outpatient TSA, as 97% of patients described their experience as good or excellent, and over 94% said they would choose outpatient TSA again.…”