Cost Comparison of Outpatient Versus Inpatient Unicompartmental Knee Arthroplasty

Safety evaluation of outpatient vs inpatient unicompartmental knee arthroplasty: a systematic review and meta-analysis

PURPOSE

This systematic review and meta-analysis aimed to evaluate the safety of outpatient and inpatient Unicompartmental Knee Arthroplasty (UKA) based on the incidence of adverse events.

METHOD

A systematic search of the literature was performed in October 2022 on PubMed, Web of Science, Cochrane library, and Embase. The Meta package for R was used to perform the meta-analysis.

RESULT

Five studies with a total of 26,301 patients were included. 5813 patients (22.1%) were treated with outpatient UKA, and 20,488 patients (77.9%) were treated with inpatient UKA. There were no statistically significant differences in the incidence of total complications (RR = 1.36, 95% CI = 0.64-2.89, Z = 0.79, P = 0.43), readmission (RR = 1.02, 95% CI = 0.40-2.60, Z = 0.05, P = 0.96), and venous thrombosis (RR = 1.43, 95% CI = 0.96-2.11, Z = 1.78, P = 0.08). Incidence rates were lower in outpatient UKA regarding urinary tract infection (RR = 1.48, 95% CI = 1.07-2.04, Z = 2.40, P = 0.02), pulmonary embolus (RR = 7.48, 95% CI = 1.80-31.17, Z = 2.76, P < 0.01), and transfusion (RR = 2.77, 95% CI = 1.63-4.71, Z = 3.78, P < 0.01).

CONCLUSION

In summary, outpatient UKA shows lower incidences of hospital-acquired complications such urinary tract infection, pulmonary embolus, and transfusion. It's worth noting that the incidences of total complications, readmission, and venous thrombosis in outpatient UKA were not higher than the incidences of inpatient UKA, suggestting that outpatient UKA can be considered a safe alternative to inpatient UKA.

The impact of insurance status on patient placement into inpatient and outpatient orthopaedic surgical centers

BACKGROUND

Innovation has fueled the shift from inpatient to outpatient care for orthopaedic joint arthroplasty. Given this transformation, it becomes imperative to understand what factors help assign care-settings to specific patients for the same procedure. While the comorbidities suffered by patients are important considerations, recent research may point to a more complex determination. Differences in reimbursement structures and patient characteristics across various insurance statuses could potentially influence these decisions.

METHODS

Retrospective binary logistic and ordinary least square (OLS) regression analyses were employed on de-identified inpatient and outpatient orthopaedic arthroplasty data from Albany Medical Center from 2018 to 2022. Data elements included surgical setting (inpatient vs. outpatient), covariates (age, sex, race, obesity, smoking status), Elixhauser comorbidity indices, and insurance status.

RESULTS

Patients insured by Medicare were significantly more likely to be placed in inpatient care-settings for total hip, knee, and ankle arthroplasty when compared to their privately insured counterparts even after Centers for Medicare and Medicaid Services (CMS) removed each individual surgery from its inpatient-only-list (1.65 (p < 0.05), 1.27 (p < 0.05), and 12.93 (p < 0.05) times more likely respectively). When compared to patients insured by the other payers, Medicare patients did not have the most comorbidities (p < 0.05).

CONCLUSIONS

Medicare patients were more likely to be placed in inpatient care-settings for hip, knee, and ankle arthroplasty. However, Medicaid patients were shown to have the most comorbidities. It is of value to note Medicare patients billed for outpatient services experience higher coinsurance rates.

LEVEL OF EVIDENCE

III.

The safety and efficacy of unicompartmental knee arthroplasty in outpatient surgical centers: A systematic review and meta-analysis

BACKGROUND

Unicompartmental knee arthroplasty (UKA) is an effective treatment method for knee osteoarthritis. With the development and implementation of enhanced recovery after surgery, UKA is now increasingly performed in outpatient surgical centers. However, there is ongoing debate regarding the safety and effectiveness of performing UKA in outpatient settings.

METHODS

The search was performed to retrieve randomized controlled trials and cohort studies on outpatient UKA from PubMed, Cochrane Library, EMbase, CNKI, and WanFangData databases. The search was conducted from the inception of the databases until August 31, 2023. After independent screening, data extraction, and risk of bias evaluation by two researchers, meta-analysis was performed using RevMan 5.4 software.

RESULTS

A total of eight studies involving 18,411 patients were included. The results showed that the postoperative transfusion rate in the outpatient group was lower than that in the inpatient group [OR = 0.36, 95%CI (0.24, 0.54), p < 0.00001], and the difference was statistically significant. However, there was no significant difference between the two groups in terms of readmission rate, reoperation rate, surgical site infection, and periprosthetic fracture. The differences were not statistically significant.

CONCLUSION

Compared to the traditional inpatient route, the blood transfusion rate for single-condyle replacement in the outpatient operation center is lower, and there is no significant difference in readmission rate, reoperation rate, surgical site infection, and periprosthesis fracture. The outpatient approach to UKA is safe, feasible, and highly satisfactory for patients. However, the results have certain limitations, and a rigorous preoperative complication risk assessment can minimize the risk of UKA in outpatient surgery centers.

TRIAL REGISTRATION

PROSPERO number CRD42023405373.

An ACS-NSQIP Analysis of Unicompartmental Knee Arthroplasty Trends from 2013 to 2018

Unicompartmental knee arthroplasty (UKA) volume has increased with advances in implant design, perioperative protocols, and patient selection. This study analyzed national trends of UKA from 2013 to 2018 and the relationship between patient demographics and postoperative outcomes. Data on UKA (CPT 27446) from 2013 to 2018 was collected from the National Surgical Quality Improvement Program (NSQIP). Variables collected included patient demographics, American Society of Anesthesiology classification, functional status, NSQIP morbidity probability, operative time, length of stay, 30-day reoperation, and readmission rates. There was an increase in outpatient UKAs performed (920 in 2013; 11,080 in 2018) (p < 0.0001). Analysis of variance from 2013 to 2018 revealed significant decrease in patient body mass index (BMI) (32.5 in 2013; 31.5 in 2018) (p < 0.01) and NSQIP morbidity probability (0.014 in 2013; 0.011 in 2018) (p < 0.0001). Operative time increased (79.1 minutes in 2013; 84.4 minutes in 2018) (p < 0.01), but length of stay decreased (0.9 days in 2013; 0.5 days in 2018) (p < 0.0001). The number of all-cause and related readmissions decreased significantly (p < 0.045; p < 0.01). Age, male gender, BMI >40 and chronic obstructive pulmonary disease (COPD) were significant predictors for 30-day readmission. BMI >40 was a significant predictor for discharge destination. UKA has seen a rise in incidence from 2013 to 2018 with an increasing number of outpatient UKAs. Operative times and 30-day readmissions have both decreased in this time. BMI > 40 is predictive for discharge destination after UKA, while age, male gender, BMI >40, and COPD are independent risk factors for 30-day readmission.

Comparison of day-case versus inpatient uni-compartmental knee replacement

BACKGROUND

Uni-compartmental knee replacement (UKR) is an alternative to total knee replacement for patients who have isolated compartment osteoarthritis. Studies have demonstrated that UKR can be safely performed as a day-case procedure without a negative impact on complication rates. The aim of this study was to compare the clinical outcomes between day-case and inpatient UKRs.

METHODS

A single surgeon prospective case-controlled study was performed, comparing data between day-case UKRs and inpatient UKRs. This included longitudinal analysis of patient reported outcome measures (PROMs); including the Oxford Knee Score, Knee Injury and Osteoarthritis Outcome Score, Short Form 12-item Health Survey, EQ-5D-5L and the Self-administered Comorbidity Questionnaire. Post-operative pain scores (visual analogue scale), unplanned post-operative hospital reattendance rates and complications were also analysed.

RESULTS

Overall, 100% of day-case patients were successfully discharged on the same day. Both inpatient (n = 23) and day-case (n = 23) UKRs demonstrated a significant within group longitudinal improvement of PROM scores (p < 0.05) following surgery. However, the post-operative PROM scores were significantly higher in the day-case group as compared to the inpatient group (p < 0.05). Both groups had comparable post-operative pain scores, but the day-case group demonstrated fewer unplanned reattendances and post-operative complications.

CONCLUSION

The clinical outcomes of day-case UKR are superior to inpatient UKR. Careful patient selection and a robust multidisciplinary patient pathway are the key components to success of day-case joint replacement surgery.

LEVEL OF EVIDENCE

Prospective Case-Control Study, level III.

Surgical Management of Facial Paralysis: Demographic and Socioeconomic Associations

Objective: To determine demographic and socioeconomic variables associated with whether surgery is performed for patients with facial paralysis (FP). Background: Management of FP may include elective surgery dependent on patient goals of care and physician experience. Methods: The 2016 State Inpatient Database and State Ambulatory Surgery Services Database for six states were queried to identify patients with FP. These patients were then stratified based on receiving surgery for FP. Demographic and socioeconomic information was collected. Multivariable logistic regression modeling was used to identify predictors of undergoing FP surgery, as well as the hospital setting in which surgery was performed. Results: Of 20,218 patients with FP, 515 underwent surgery. Black patients were significantly less likely to undergo surgery (p < 0.001), as were patients with Medicaid or self-pay insurance (p < 0.001). Those living in rural areas were also less likely to receive surgery (p = 0.001). Individuals receiving surgery in the inpatient setting were more likely to have private insurance, whereas those in the ambulatory setting were more likely to have Medicare (p < 0.001). Conclusion: Several variables are correlated with whether FP is managed surgically, including insurance status, race, and type of residential area.

Unicompartmental Knee Arthroplasty Is Cost-Effective in an Outpatient Setting

INTRODUCTION

Increasingly, unicompartmental knee arthroplasty (UKA) is being performed on an outpatient basis, with the growing utilization of ambulatory surgery centers (ASCs). The purpose of this study was to compare the costs of UKAs performed in an ASC to UKAs done in a hospital, either on an outpatient or inpatient basis.

METHODS

This study involved three matched groups, each with 50 consecutive patients, undergoing UKA either on an outpatient basis in an ASC or a community hospital, or who were admitted overnight to the same community hospital. Identical perioperative analgesic regimens and care protocols were used in each group. The primary outcomes evaluated included direct facility costs. Secondary outcomes were postoperative complications and readmissions.

RESULTS

Average age, gender ratio, and comorbidities were similar in all three cohorts. Only two patients in the study experienced complications and these were without secondary adverse consequences. Mean costs were substantially reduced when UKAs were performed in an ASC ($9,025) compared to a community hospital on either an outpatient ($12,032) or inpatient basis ($14,542).

CONCLUSION

UKA can be safely performed in the outpatient setting, in appropriately selected patients, at substantial cost savings, particularly when performed in an ASC.

Outpatient inguinal hernia repair in Spain: a population-based study of 1,163,039 patients-clinical and socioeconomic factors associated with the choice of day surgery

Reducing inpatient admissions and health care costs is a central aspiration of worldwide health systems. This study aimed to evaluate trends in outpatient surgery in inguinal hernia repair (IHR) and factors related to the outpatient setting in Spain. A retrospective cohort study (Record-Strobe compliant) of 1,163,039 patients who underwent IHR from January 2004 to December 2019 was conducted. Data were extracted from the public clinical administrative database CMBD ("Conjunto Mínimo Básico de Datos"). The primary outcome was the outpatient surgery rate. Univariate and multivariable analyses were performed to identify clinical and socioeconomic factors related to the outpatient setting. The overall proportion of outpatient repairs was 30.7% in 2004 and 54.2% in 2019 (p < 0.001). Treatment in a public hospital was the most remarkable factor associated with the likelihood of receiving an outpatient procedure (OR 3.408; p < 0.001). There were also significant differences favouring outpatient procedures for patients with public insurance (OR 2.351; p < 0.001), unilateral hernia (OR 2.903; p < 0.001), primary hernia (OR 1.937; p < 0.0005), age < 65 years (OR 1.747; p < 0.001) and open surgery (OR 1.610; p < 0.001). Only 9% of patients who pay for their intervention privately or 15% of those covered by private insurance were treated as outpatients. Spain has significantly increased the rate of outpatient IHR over the last 16 years. However, the figures obtained still leave a significant margin for improvement. Important questions about the acceptance of outpatient settings remain to be answered. Outpatient inguinal hernia repair in Spain. A population-based study of 1,163,039 patients: clinical and socioeconomic factors associated with the choice of day surgery.

Successful same-day discharge in 88% of patients after unicompartmental knee arthroplasty: a systematic review and meta-analysis

PURPOSE

The purpose of this study was to evaluate the effectiveness of day-case unicompartmental knee arthroplasty (UKA) by assessment of successful same-day discharge (SDD), readmission, complication and reoperation rates in the recent literature.

METHODS

For this systematic review and meta-analysis, PubMed, Embase and Cochrane Library were comprehensively searched to identify all eligible studies reporting outcomes of day-case UKA. Studies with intended same-day home discharge after UKA were included. A meta-analysis of proportions, using a random-effects model, was performed to estimate overall rates of successful SDD and adverse events. Subgroup analyses were performed for studies including selected patients (i.e., patients had to meet certain patient-specific criteria to be eligible for day-case UKA) and unselected patients (i.e., no additional criteria for day-case UKA), as well as for clinical and registry-based studies. Additional outcomes included reasons for the failure of SDD and patient satisfaction.

RESULTS

A total of 29 studies and 9694 patients were included with a mean age of 66 ± 9 years and mean follow-up of 59 days (mean range 30-270 days). Based on 24 studies (2733 patients), the overall successful SDD rate was 88% (95% confidence interval [CI] 80-92). These rates were 91% (95% CI 84-95) across studies with selected patients and 76% (95% CI 55-89) across studies with unselected patients. Overall readmission, complication and reoperation rates were 3% (95% CI 1.9-4.4), 4% (95% CI 2.8-5.2) and 1% (95% CI 0.8-1.3), respectively. Inability to mobilize, nausea and uncontrolled pain were frequently reported reasons for failed SDD. The overall patient satisfaction rate was 94%.

CONCLUSION

This systematic review with meta-analysis found an overall successful SDD rate of 88% after UKA in a heterogeneous cohort of selected and unselected patients. Readmission, complication and reoperation rates suggest UKA can be performed safely and effectively as a same-day discharge procedure.

LEVEL OF EVIDENCE

Level IV, systematic review of level III and IV studies.

A standardized technique for lateral unicompartmental knee arthroplasty

OBJECTIVES

We developed a new standardized procedure for lateral unicompartmental knee arthroplasty (UKA) to maximize the benefits and minimize the risks of surgery in patients with osteoarthritis (OA).

METHODS

This retrospective study recruited patients who underwent lateral UKA at our hospital between January 2014 and January 2016. Demographic characteristics and preoperative and postoperative American Knee Society (AKS) clinical scores (including pain, clinical, and knee mobility scores) were collected.

RESULTS

A total of 158 patients (35 male and 123 female) who underwent 160 lateral UKAs were analyzed. Their AKS clinical scores (0-100 points) improved from 53.1 ± 4.1 (range 45-62) preoperatively to 97.0 ± 1.7 (range 92-99) (p < 0.001) postoperatively with additional improvements of 9.1 ± 1.8 (range 3-14) to 47.3 ± 1.5 (range 45-49) (p < 0.001) for pain, 49.7 ± 9.7 (range 35-70) to 97.1 ± 4.1 (range 90-100) (p < 0.001) for function, and 105.0 ± 4.4° (equivalent to ∼100-115°) to 125.5 ± 5.3° (∼110-135°) (p < 0.001) for a range of motion (ROM). No patients required reoperations or revisions. Two patients were readmitted within 60 days due to severe knee swelling.

CONCLUSION

The lateral UKA protocol was reproducible and the patients had a good postoperative outcomes. Yet, large-scale, multi-center, prospective studies are needed to further confirm our findings.

Safety and efficacy of outpatient hip and knee arthroplasty: a systematic review with meta-analysis

INTRODUCTION

This systematic review aimed to assess the safety and efficacy of outpatient joint arthroplasty (OJA) pathways compared to inpatient pathways.

MATERIALS AND METHODS

An electronic literature search was conducted to identify eligible studies. Studies comparing OJA with inpatient pathways-following hip and/or (partial) knee arthroplasty-were included. Included studies were assigned-based on OJA definition-to one of the following two groups: (1) outpatient surgery (OS); outpatient defined as discharge on the same day as surgery; and (2) semi-outpatient surgery (SOS); outpatient defined as discharge within 24 h after surgery with or without an overnight stay. Methodological quality was assessed. Outcomes included (serious) adverse events ((S)AEs), readmissions, successful same-day discharge rates, patient-reported outcome measures (PROMs) and costs. Meta-analyses and subgroup analyses by type of arthroplasty were performed when deemed appropriate.

RESULTS

A total of 41 studies (OS = 26, SOS = 15) met the inclusion criteria. One RCT and 40 observational studies were included, with an overall risk-of-bias of moderate to high. Forty studies were included in the meta-analysis. Outpatients (both OS and SOS) were younger and had a lower BMI and ASA class compared to inpatients. Overall, no significant differences between outpatients and inpatients were found for overall complications and readmission rates, and improvement in PROMs. By type of arthroplasty, only THAs in OS pathways were associated with fewer AEs [OR = 0.55 (0.41-0.74)] compared to inpatient pathways. 92% of OS patients were discharged on the day of surgery. OJA resulted in an average cost reduction of $6.797,02.

CONCLUSION

OJA pathways are as safe and effective as inpatient pathways in selected populations, with a potential reduction of costs. Considerable risk of bias in the majority of studies emphasizes the need for further research.

Same-Day Outpatient Lower-Extremity Joint Replacement: A Critical Analysis Review

➢ The economics of transitioning total joint arthroplasty (TJA) to standalone ambulatory surgery centers (ASCs) should not be capitalized on at the expense of patient safety in the absence of established superior patient outcomes. ➢ Proper patient selection is essential to maximizing safety and avoiding complications resulting in readmission. ➢ Ambulatory TJA programs should focus on reducing complications frequently associated with delays in discharge. ➢ The transition from hospital-based TJA to ASC-based TJA has substantial financial implications for the hospital, payer, patient, and surgeon.

Cost-effectiveness of Same-day Discharge Surgery for Primary Total Hip Arthroplasty: A Pragmatic Randomized Controlled Study

Background

Total hip arthroplasty (THA) causes a great medical burden globally, and the same-day discharge (SDD) method has previously been considered to be cost saving. However, a standard cost-effectiveness analysis (CEA) in a randomized controlled trial (RCT) is needed to evaluated the benefits of SDD when performing THA from the perspective of both economic and clinical outcomes.

Methods

Eighty-four participants undergoing primary THA were randomized to either the SDD group or the inpatient group. Outcomes were assessed by an independent orthopedist who was not in the surgical team, using the Oxford Hip Score (OHS), EuroQol 5D (EQ-5D), SF-36 scores and the quality-adjusted life years (QALYs). All the cost information was also collected.

Results

The mean stay of patients in the SDD group was 21.70 ± 3.45 h, while the inpatient group was 78.15 ± 26.36 h. This trial did not detect any significant differences in OHS and QALYs. The total cost in the SDD group was significantly lower than that in the inpatient group (¥69,771.27 ± 6,608.00 vs. ¥80,666.17 ± 8,421.96, p < 0.001). From the perspective of total cost, when measuring OHS, the incremental effect was -0.12 and the incremental cost was -¥10,894.90. The mean incremental cost-effectiveness ratio (ICER) was 90,790.83. When measuring QALYs, the incremental effect was 0.02, and the ICER was negative. Sensitivity analysis produced similar results.

Conclusions

SDD has an acceptable likelihood of being more cost-effective than the traditional inpatient option. After conducting cost-utility analysis, SDD resulted in better QALYs, while significantly reducing the total cost.

Impact of enhanced recovery pathways on safety and efficacy of hip and knee arthroplasty: A systematic review and meta-analysis

BACKGROUND

Over the past decades, clinical pathways (CPs) for hip and knee arthroplasty have been strongly and continuously evolved based on scientific evidence and innovation.

AIM

The present systematic review, including meta-analysis, aimed to compare the safety and efficacy of enhanced recovery pathways (ERP) with regular pathways for patients with hip and/or knee arthroplasty.

METHODS

A literature search in healthcare databases (Embase, PubMed, Cochrane Library, CINAHL, and Web of Science) was conducted from inception up to June 2018. Relevant randomized controlled trials as well as observational studies comparing ERP, based on novel evidence, with regular or standard pathways, prescribing care as usual for hip and/or knee arthroplasty, were included. The effect of both CPs was assessed for (serious) adverse events [(S)AEs], readmission rate, length of hospital stay (LoS), clinician-derived clinical outcomes, patient reported outcome measures (PROMs), and financial benefits. If possible, a meta-analysis was performed. In case of considerable heterogeneity among studies, a qualitative analysis was performed.

RESULTS

Forty studies were eligible for data extraction, 34 in meta-analysis and 40 in qualitative analysis. The total sample size consisted of more than 2 million patients undergoing hip or knee arthroplasty, with a mean age of 66 years and with 60% of females. The methodological quality of the included studies ranged from average to good. The ERP had lower (S)AEs [relative risk (RR): 0.9, 95% confidence interval (CI): 0.8-1] and readmission rates (RR: 0.8, 95%CI: 0.7-1), and reduced LoS [median days 6.5 (0.3-9.5)], and showed similar or improved outcomes for functional recovery and PROMs compared to regular pathways. The analyses for readmission presented a statistically significant difference in the enhanced recovery pathway in favor of knee arthroplasties (P = 0.01). ERP were reported to be cost effective, and the cost reduction varied largely between studies (€109 and $20573). The overall outcomes of all studies reported using Grading of Recommendation, Assessment, Development and Evaluation, presented moderate or high quality of evidence.

CONCLUSION

This study showed that implementation of ERP resulted in improved clinical and patient related outcomes compared to regular pathways in hip and knee arthroplasty, with a potential reduction of costs.

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

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 Emnbase, 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 significance 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 finding more readmissions after inpatient TSA. Complications were more common in inpatient TSA in five 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 cost-effective 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 profiles between outpatient and inpatient TSA.

LEVEL OF EVIDENCE

Level IV; systematic review.

On the generalizability of same-day partial knee replacement surgery-A non-selective interventional study evaluating efficacy, patient satisfaction, and safety in a public hospital setting

PURPOSE

Programs referred to as Fast-Track/Rapid Recovery/Enhanced Recovery After Surgery have proven both effective and safe in joint replacement surgery, to the degree where same-day discharge (SDD) has been attempted in carefully selected cases at specialized outpatient units. Therefore, the primary aim of this study was to evaluate a same-day surgery protocol regarding safety using the minor partial knee replacement (PKR) procedure by non-selectively recruiting patients at a public hospital for one consecutive year.

METHODS

33 unselected PKR cases were included in this open clinical trial. The inclusion/exclusion criteria were solely based on logistics, as all the procedures were medial PKRs, designated the first morning slots, and performed by one single-surgeon. Strict postoperative criteria based on vital parameters, urinary function, bleeding, and mobilization had to be met before discharge was considered. SDD rate, patient satisfaction, number of outpatient visits, adverse events and readmissions within 90 days were evaluated. A predetermined subgroup analysis was also conducted where patients <80 yrs. and with an American Society of Anesthesiologists (ASA) classification <III was compared with those aged ≥80 yrs. and/or ASA class ≥III.

RESULTS

29 of 33 (88%) successfully achieved SDD. In a univariate comparison, 100% of the patients <80 yrs. and ASA class <III achieved SDD, whereas a corresponding 43% applied for those aged ≥80 yrs. and/or ASA class ≥III (p = 0.001). A 93% overall satisfaction rate was reached. Only 8% extra outpatient visits were required, all occurring within the first 2 weeks (well in line with routine practice.) One plausible transient ischemic attack and one readmission caused by a penetrating trauma not affecting the knee were identified, both of which happened 10 weeks after surgery. No adverse events or readmissions occurred within the first 48 hours of surgery.

CONCLUSION

When following strict criteria for discharge, same-day partial knee replacement surgery may be both feasible and safe, even without preselection of patients.

The patient perspective, experience and satisfaction of day case unicompartmental knee arthroplasty: A short-term mixed-methods study

BACKGROUND

Day case unicompartmental knee arthroplasty (UKA) is increasingly being performed worldwide. When performed in the appropriate patient, day case UKA has been demonstrated to be safe, cost effective and improve resource allocation. Limited evidence highlights increased patient satisfaction of day case UKA when compared with inpatient UKA. A detailed study of the patient perspective, experience and satisfaction following day case UKA has not been described before.

METHODS

A retrospective case series review of 21 consecutive patients (19 unilateral, 2 bilateral) undergoing day case UKA in an elective orthopaedic centre was undertaken. A qualitative and quantitative patient assessment of the day case UKA experience was administered. A five-point Likert scale satisfaction questionnaire, Oxford Knee Score (OKS) and open-ended interview was undertaken. The qualitative responses underwent thematic analysis.

RESULTS

One hundred percent of patients expressed satisfaction (76.2% completely satisfied, 33.8% moderately satisfied) with day case UKA. The majority of patients (90.5%) reported that if they had to undergo UKA again they would prefer a day case over an inpatient procedure. Patients consider surgical outcome, physiotherapy provision, discharge planning, postoperative medications and follow up as key aspects of day case UKA care. One patient was re-admitted following discharge.

CONCLUSIONS

The present study demonstrates a high level of patient satisfaction with day case UKA. The results reported herein are subject to the study limitations of sample size, recall bias and inclusion criteria. We recommend that the themes identified by patients are addressed through a multidisciplinary approach with well-defined clinical pathways for a high-quality patient-centred experience.

Fewer Adverse Events Following Outpatient Compared with Inpatient Unicompartmental Knee Arthroplasty

BACKGROUND

Unicompartmental knee arthroplasty (UKA) is a common procedure for unicompartmental knee arthritis, often resulting in pain relief and improved function. The demand for total knee arthroplasty in the U.S. is projected to grow 85% between 2014 and 2030, and the volume of UKA procedures is growing 3 to 6 times faster than that of total knee arthroplasty. The purpose of the present study was to examine the safety of outpatient and inpatient UKA and to investigate changes over time as outpatient procedures were performed more frequently.

METHODS

Patients who underwent UKA from 2005 to 2018 as part of the National Surgical Quality Improvement Program were identified. Patients were divided into an early cohort (5,555 patients from 2005 to 2015) and late cohort (5,627 patients from 2016 to 2018). Outpatient status was defined as discharge on the day of surgery. Adverse events within 30 days postoperatively were compared, with adjustment for baseline characteristics with use of standard multivariate regression and propensity-score-matching techniques.

RESULTS

Among the 5,555 cases in the early cohort, the rate of surgical-site infection was lower for inpatient (0.84%) compared with outpatient UKA (1.69%; adjusted relative risk [RR] for inpatient, 0.5; 95% confidence interval [CI], 0.2 to 1.0; p = 0.045); no other significant differences were identified. Among the 5,627 cases in the late cohort, inpatient UKA had higher rates of any complication (2.53% compared with 0.95% for outpatient UKA; adjusted RR for inpatient, 2.5; 95% CI, 1.4 to 4.3; p = 0.001) and readmission (1.81% compared with 0.88% for outpatient UKA; adjusted RR for inpatient, 2.0; 95% CI, 1.1 to 3.5; p = 0.023). In the propensity-score-matched comparison for the late cohort, inpatient UKA had a higher rate of any complication (RR for inpatient, 2.0; 95% CI, 1.0 to 4.0; p = 0.049) and return to the operating room (RR for inpatient, 4.3; 95% CI, 1.4 to 12.6; p = 0.009). Although the rate of readmission was almost twice as high among inpatients (1.67% compared with 0.84% for outpatients; RR for inpatient, 2.0; 95% CI, 1.0 to 4.1; p = 0.059), this difference did not reach significance with the sample size studied. There was a significant reduction in the overall rate of complications over time (3.44% in the early cohort compared with 2.11% in the late cohort; adjusted RR for late cohort, 0.7; 95% CI, 0.5 to 0.8; p = 0.001), with a more than fourfold reduction among outpatients (3.95% in the early cohort compared with 0.95% in the late cohort; adjusted RR for late cohort, 0.3; 95% CI, 0.1 to 0.5; p < 0.001).

CONCLUSIONS

Outpatient UKA was associated with a lower risk of complications compared with inpatient UKA when contemporary data are examined. We identified a dramatic reduction in complications across the early and late cohorts, suggesting an improvement in quality over time, with the largest improvements seen among outpatients. This shift may represent changes in patient selection or improvements in perioperative protocols.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Day case unicompartmental knee replacement: An update of the Torbay experience

BACKGROUND

Hospitals throughout the United Kingdom face significant challenges in regards to inpatient bed capacity, leading to growing interest in day case arthroplasty. Day case Unicompartmental Knee Replacement (UKR) has been offered within our unit since 2010, with successive evaluations of pathway outcomes performed in 2011 and 2015. Since then, our day case UKR pathway has expanded. This study aims to evaluate the safety, efficiency and patient satisfaction with this expanded pathway.

METHODS

Data was prospectively collected for all patients undergoing a UKR between January 2017 and August 2019. Data collected included the pathway planned, date of admission, date of discharge and re-admissions to hospital within 30 days of surgery. Patient satisfaction was evaluated via a follow-up questionnaire.

RESULTS

109 patients underwent a UKR between January 2017 and August 2019. 83 patients (76%) were planned through the day case pathway. 63 patients were successfully discharged on the day of surgery. One day case pathway and two inpatient pathway patients were re-admitted within 30 days of surgery with medical conditions. A high level of patient satisfaction with our day case pathway was identified.

CONCLUSION

UKR with planned discharge on the day of surgery is possible for a large proportion of patients provided that robust pathway and protocol design is undertaken. Following 10 years' experience, our day case UKR pathway has increasingly become the default for the majority of our patients. We report high patient satisfaction and low 30-day re-admission rates. However, 100% success rate for day of surgery discharge remains challenging.

The cost-effectiveness of outpatient surgery for primary total hip arthroplasty in the United States: a computer-based cost-utility study

PURPOSE

The purpose of this study was to perform a cost-effectiveness analysis of outpatient versus inpatient total hip arthroplasty (THA) in the USA, considering complication probability and the potential cost of such complications.

METHODS

A cost-effectiveness analysis was conducted from the societal perspective to evaluate the incremental cost and effectiveness of inpatient THA compared to outpatient THA over a lifetime horizon. Effectiveness was expressed in quality-adjusted life years (QALYs). Costs, expressed in 2019 US dollars, transition probabilities, and health utilities were derived from the literature. The primary outcome was the incremental cost-effectiveness ratio (ICER), with a willingness to pay (WTP) threshold set at $50,000/QALY. 1-way and probabilistic sensitivity analyses was performed to evaluate the effect of the various variables on the model.

RESULTS

In the base case, inpatient THA was more effective in terms of total utility (10.36 vs. 10.30 QALY), but also more costly ($48,155 ± 1673 vs. $43,288 ± 1, 606 for Medicare) than outpatient THA. Even with a lifetime horizon, the ICER was $81,116 per QALY and $140,917 per QALY for Medicare and private payer insurance, respectively, which is higher than the willingness to pay threshold. 1-way sensitivity analyses indicated that the variables having the most influence on the model were the utility of inpatient and outpatient THA and cost of inpatient and outpatient THA.

CONCLUSIONS

This model determined that for a WTP threshold set at $50,000/QALY, outpatient THA is more cost-effective than inpatient THA from a societal perspective. Despite this, surgeons must weigh clinical factors first and foremost in determining if an individual patient can be safely operated on in the outpatient setting.

Day-case unicompartmental knee arthroplasty: a literature review and development of a novel hospital pathway

INTRODUCTION

We have seen unparalleled changes in our healthcare systems globally as a result of the COVID-19 pandemic. As we strive to regenerate our full capacity elective services in order to contest the increasing demand for lower limb arthroplasty, this pandemic has allowed us a rare opportunity to revise and develop novel elective arthroplasty pathways intended to improve patient care and advance healthcare efficiency. We present an extensive evidence-based review of the approaches used to achieve day-case unicompartmental arthroplasty (UKA) as well as the development of a day-case UKA care pathway in a UK NHS institution based on the evidence provided in the literature.

METHODS

An extensive search of the literature was performed for articles that reported on readmission or complication rates ≥30 days postoperatively following day-case UKA.

FINDINGS

Fifteen manuscripts reporting the results of day-case UKA, defined as discharged on the same calendar day of surgery, were included in our review. Mean reported complication rates for day-case and inpatient UKA within the follow-up periods were 4.05% and 6.52%, respectively. Mean readmission rates were 2.71% and 4.36% for day-case and inpatient UKA, respectively. The mean rate of successful same-day discharge was 92.45%.

CONCLUSION

We introduce our institutional Elective Day Surgery Arthroplasty Pathway (EDSAP) founded upon the evidence presented in the literature. Stringent patient selection complimented by a well-defined day-case arthroplasty pathway is fundamental for successful commencement of day-case UKA in the NHS.

What is the evidence for clinical use of advanced technology in unicompartmental knee arthroplasty?

BACKGROUND

With an aim of improving prosthesis survivorship of unicompartmental knee arthroplasty (UKA), use of computer-assisted technologies (CATs) such as robotics, has been on the rise to reduce intraoperative errors in surgical technique. In light of recent influx of CATs in the UKA, a review of these innovations will help providers to understand their clinical utility.

METHOD

A systematic literature search was performed following Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines.

RESULTS

Among 19 studies comparing robot-assisted UKA with conventional UKA, only 32% were randomized control trials, 47% reported minimum mean follow-up of 2 years, and 21% evaluated prosthesis survival. Similar results were obtained for navigation-assisted UKA and UKA performed with patient-specific instrumentation.

CONCLUSION

While CATs seem to reduce the surgical errors in UKA, the evidence on the efficacy of any of the studied CATs to improve survivorship remains limited and there are issues related to cost-effectiveness, learning curve, and increase in operating time.

Defining Outpatient Hip and Knee Arthroplasties: A Systematic Review

INTRODUCTION

The term "outpatient" has a variety of meanings regarding the location of arthroplasty and the duration of stay postoperatively. The purpose of this systematic review was to evaluate the literature and more accurately define the term "outpatient."

METHODS

A PubMed search (2014 to 2019) using the terms "outpatient AND arthroplasty" identified 76 studies; 35 studies that met the inclusion criteria were assessed to determine the definition of "outpatient." The level of evidence, type of arthroplasty, location of surgery (hospital or ambulatory surgery center [ASC]), approach used for hip arthroplasty, number of patients, number of surgeons, and length of time the patients were kept at the location after surgery were evaluated.

RESULTS

Arthroplasties analyzed were total hip (11), total knee (seven), unicompartmental knee (five), and hip and knee (12). Only 16.8% of surgeries defined as outpatient hip or knee arthroplasty were done in a freestanding ASC, and 44.2% of patients defined as outpatients were kept overnight for the 23-hour observation.

DISCUSSION

We propose "DASH" (Discharge from ASC to Home) as a new term to define arthroplasties done in an outpatient setting with the patient discharged home the same day.

Outpatient Versus Inpatient Surgical Fixation of Isolated Ankle Fractures: An Analysis of 90-Day Complications, Readmissions, and Costs

Despite increasing interest toward managing isolated ankle fractures in an outpatient setting, evidence of its safety remains largely limited. The 2007 to 2014 Humana Administrative Claims database was queried to identify patients undergoing open reduction internal fixation for unimalleolar, bimalleolar, or trimalleolar isolated closed ankle fractures. Two cohorts (outpatient versus inpatient) were then matched on the basis of age, sex, race, region, fracture type (uni-/bi-/trimalleolar) and Elixhauser Comorbidity Index to control for selection bias. Multivariate regression analyses were performed to report independent impact of outpatient-treated ankle fracture surgery on 90-day complications, readmission, and emergency department visit rates. Independent-samples t test was used to compare global 90-day costs between cohorts. A total of 5317 inpatient-treated and 6941 outpatient-treated closed ankle fractures were included in the final cohort. After matching and multivariate analyses, patients with outpatient ankle fractures, compared with patients with inpatient ankle fractures, had statistically lower rates of pneumonia (2.3% versus 4.0%; p < .001), myocardial infarction (0.9% versus 1.8%; p = .005), acute renal failure (2.2% versus 5.3%; p < .001), urinary tract infections (7.4% versus 12.3%; p < .001), and pressure ulcers (0.9% versus 2.0%; p = .001). Outpatient ankle fractures also had lower rates of 90-day readmissions (9.7% versus 14.1%; p < .001) and emergency department visits (13.8% versus 16.2%; p = .028). Last, overall 90-day costs for outpatient ankle fractures were nearly $9000 lower than costs for inpatient ankle fractures ($12,923 versus $21,866; p < .001). Based on our findings, it appears that outpatient treatment of ankle fractures can be deemed safe and feasible in a select cohort of patients.

Removing Medicare's outpatient ban and Medicare and private surgical trends

OBJECTIVES

To examine changes in hospital outpatient surgery trends and case mix for Medicare and privately insured patients needing total knee arthroplasty (TKA) following Medicare's removal of TKA from its Inpatient Only list on January 1, 2018.

STUDY DESIGN

A retrospective analysis of all hospital discharge records in Florida from 2012 through 2018.

METHODS

We tracked inpatient vs outpatient performance of TKAs at the state and hospital levels. We also combined our primary data with physician practice organization information to assess variation in the policy response according to physician-hospital ownership status. Supplementary analyses examined policy-induced changes in inpatient TKA case mix.

RESULTS

We observed an immediate shift of roughly 15% of Medicare TKA cases to the outpatient setting. Importantly, there was a simultaneous near doubling of the number of TKAs performed as a hospital outpatient procedure among privately insured patients younger than 60 years. Hospitals allocated a similar proportion of TKA cases to the outpatient setting across the 2 payer groups, and we found evidence of selection against the potentially riskiest Medicare TKA patients for outpatient delivery. Vertically integrated orthopedic physicians retained their Medicare and privately insured TKA cases within the inpatient (higher-cost) setting.

CONCLUSIONS

Market and financial pressures are encouraging more outpatient care delivery; however, the speed of transition is dictated, in part, by regulatory constraints. Our results suggest that Medicare policy may influence surgical treatment approaches for Medicare and privately insured patients. Spillover implications need to be considered when weighing future Medicare regulatory decisions.

Analysis of patient characteristics, health care costs by surgical venue, and opioid utilization for common orthopedic procedures in the United States

BACKGROUND: Orthopedic surgery can be performed in hospital outpatient departments (HOPDs) and ambulatory surgical centers (ASCs), as well as in traditional inpatient venues. Patients who undergo orthopedic surgery may be prescribed opioids for the management of postsurgical pain. However, the association between surgery venue, postsurgical opioid use, and health care costs remains unclear. OBJECTIVE: To compare postsurgical opioid use and health care costs associated with 6 different orthopedic surgical procedures performed at inpatient, ASC, and HOPD venues. METHODS: Using the Optum Research Database, this retrospective study analyzed commercial health care claims from adult patients in the United States undergoing specific orthopedic procedures (total knee arthroplasty, partial knee arthroplasty, total hip arthroplasty, total shoulder arthroplasty, rotator cuff repair, and lumbar spinal fusion) between April 1, 2012, and December 31, 2017. The date of the first procedure in that period was the index date; continuous insurance coverage for 12 months before the index date (baseline period) to 6 months following the index date (postsurgical period, which includes the index date) was required. Opioid use and all-cause costs were measured in the postsurgical period. Baseline patient characteristics included demographics, Quan-Charlson Comorbidity Index, and opioid use. Multivariable analysis identified factors influencing postsurgical costs and persistent opioid use (defined as ≥ 1 opioid fill within 3 days after surgery [or discharge for inpatient stay] and ≥1 additional opioid fill during the postsurgical period at least 90 days after the index date). RESULTS: The sample included 126,172 patients (mean age, 58 years; 49% female). Overall, most procedures were performed at inpatient venues (68%), followed by HOPDs (18%) and ASCs (14%); the percentage of procedures performed at ASCs increased from 12% to 17% from 2012 to 2017. Patients whose procedures were performed at ASCs reported the lowest adjusted percentage of persistent opioid use following the procedure (18%) compared with those with procedures performed at HOPDs (24%) or inpatient venues (26%). Adjusted 30-day costs were 14% and 27% lower for patients with procedures in HOPDs and ASCs, respectively, compared with inpatient venues (P < 0.001 for both), and adjusted costs over the first 90 days were similar. CONCLUSIONS: All-cause costs on the day of surgery through 30 days after surgery for these 6 orthopedic procedures were significantly lower in HOPDs and ASCs compared with inpatient venues, even after adjustment for cohort, surgery year, demographic characteristics, baseline Quan-Charlson Comorbidity Index, and any opioid use within 90 days before the procedure. Additionally, patients undergoing orthopedic surgery at ASCs had the lowest adjusted percentage of persistent opioid use compared with those undergoing surgery at HOPDs or inpatient venues. Migration of certain orthopedic procedures from inpatient venues to HOPDs or ASCs may reduce health care costs and decrease the potential for persistent opioid use. DISCLOSURES: This study and editorial support for the preparation of this manuscript was funded by Pacira BioSciences, which contracted with Optum to conduct the study. Cisternas, Korrer, and Wilson are employees of Optum. Waterman was employed with Pacira BioSciences at the time of the study. Portions of this work were presented at AMCP Nexus 2019; October 29-November 1, 2019; National Harbor, MD.

Ambulatory-Based Bladder Outlet Procedures Offer Significant Cost Savings and Comparable 30-Day Outcomes Relative to Inpatient Procedures

Introduction and Objectives: Budgetary constraints and novel minimally invasive surgical approaches have resulted in surgical care being increasingly provided at ambulatory centers rather than traditional inpatient settings. Despite increasing use of ambulatory-based procedure for bladder outlet obstruction (BOO) procedures, little is known about the effect of care setting on perioperative outcomes and costs. We sought to compare 30-day readmissions rates and costs of BOO procedure performed in the ambulatory vs inpatient setting. Methods: Using Florida and New York all-payer data from the 2014 Healthcare Cost and Utilization Project State Databases, we identified patients who underwent transurethral resection, thermotherapy, or laser/photovaporization for BOO. Patient demographics, regional data, 30-day readmissions rates, and costs (from converted charges) associated with the index procedure and revisits were analyzed. Predictors of 30-day revisits were also identified by fitting a multivariate logistic regression model with facility-level clustering. Results: Of the 15,094 patients identified, 1444 (9.6%) had a 30-day revisit at a median cost of $4263.43. The 30-day readmission rate for inpatient cases was significantly higher than that of surgeries performed in the ambulatory setting (12.0% vs 8.1%, p < 0.001). Payer status (private vs Medicare: odds ratio [OR] = 0.77, 95% confidence interval [CI] = 0.62-0.95; p = 0.02) and index care setting (ambulatory vs inpatient: OR = 0.48, 95% CI = 0.40-0.57; p < 0.001) predicted 30-day revisits. Conclusions: We identified that index care setting and payer status are independent predictors of 30-day revisit after BOO procedure, with the inpatient setting and Medicare insurance associated with higher odds of revisit. Ambulatory procedures are significantly less costly than procedures performed in the inpatient setting, even after accounting for ambulatory procedures leading to an admission. There is an obvious cost benefit of offering BOO procedure in the ambulatory setting to the appropriate patient. In the context of value-based health care initiatives, our findings have important implications for policymakers seeking to reduce variation in nonclinical sources of perioperative costs and outcomes.

Why are patients still in hospital after fast-track, unilateral unicompartmental knee arthroplasty

Background and purpose - Previous studies have investigated risk factors related to prolonged length of stay following total knee arthroplasty (TKA), but little is known about specific factors resulting in continued hospitalization within the 1st postoperative days after unicompartmental knee arthroplasty (UKA). We investigated what specific factors prevent patients from being discharged on the day of surgery (DOS) and the first postoperative day (POD-1) following primary UKA in a fast-track setting.Patients and methods - We prospectively collected data on 100 consecutive and unselected medial UKA patients operated from December 2017 to May 2019. All patients were operated in a standardized fast-track setup with functional discharge criteria continuously evaluated from DOS and until discharge.Results - Median length of stay for the entire cohort was 1 day. 22% and 78% of all patients were discharged on DOS and POD-1, respectively. Lack of mobilization and pain separately delayed discharge in respectively 78% and 24% of patients on DOS. The main reasons for lack of mobilization were motor blockade (37%) and logistical factors (26%). For patients placed 1st or 2nd on the operating list, we estimate that the same-day discharge rate would increase to 55% and 40% respectively, assuming that pain and mobilization were successfully managed.Interpretation - One-fifth of unselected UKA patients operated in a standardized fast-track setup were discharged on DOS. Pain and lack of mobilization were the major reasons for continued hospitalization within the initial postoperative 24-48 hours. Strategies aimed at decreasing length of stay after UKA should strive to improve analgesia and postoperative mobilization.

Reimbursement and Complications in Outpatient vs Inpatient Unicompartmental Arthroplasty

BACKGROUND

Increasing utilization of unicompartmental knee arthroplasty (UKA) has driven a greater push for outpatient treatment and cost containment in the setting of bundled payments. The purpose of this study is to evaluate utilization trends of inpatient vs outpatient UKA, index episode and 90-day reimbursement, and any differences in medical or surgical complications.

METHODS

The PearlDiver database was employed to identify all inpatient and outpatient UKAs performed between 2007 and 2016 with 2-year follow-up. Patients were matched by age, gender, and Elixhauser Comorbidity Index. We tracked index procedure and global period reimbursement, 90-day medical and surgical complications, and 2-year surgical complications.

RESULTS

The reimbursement and utilization cohort included 3181 outpatient and 5490 inpatient UKAs. Outpatient UKA and overall utilization of UKA increased over the study period. Mean index reimbursement of inpatient UKA was $2486.16 higher per procedure (P < .001) while mean global period reimbursement was $2782.13 higher per inpatient procedure (P < .001). Ninety-day medical complications including postoperative anemia (P < .001), transfusion (P = .024), and arrhythmia (P = .004) were more common with inpatient UKAs, whereas surgical wound complications (P = .001) and operative debridement (P = .028) were more common among outpatient UKAs. Outpatient UKA was not associated with an increased risk of periprosthetic joint infection (P > .05), aseptic loosening (P > .05), or revision surgery (P > .05) when compared to inpatient UKA.

CONCLUSION

Outpatient UKA utilization is increasing and is associated with decreased reimbursement compared to inpatient UKA without increased risk of major medical complications, although it is associated with increased risk of wound complication and need for operative debridement at 90 days.

Assessing Rapidity of Recovery After Cancer Surgeries in a Single Overnight Short-Stay Setting

BACKGROUND

In the short-stay surgery setting, where patients remain in hospital for a single overnight at most, it is unclear as to whether postoperative length of stay is a good surrogate for assessing rapidity of recovery. We hypothesized that length of stay would be a function of time of surgery and would be a poorer marker of recovery than time of discharge.

METHODS

A cohort of 891 mastectomy and 538 prostatectomy patients had a planned single overnight stay after surgery at an ambulatory surgical hospital during 2016. The relationship between surgical start time and postoperative length of stay or discharge time was assessed.

RESULTS

For both mastectomy and prostatectomy patients, 75% of patients were discharged between 10 AM and 12 noon and the median postoperative length of stay was 20 hours. There was a strong association between time of surgery and calculated length of stay. For mastectomies, having a surgery which begins at 6 PM vs 8 AM results in an estimated decrease of 8.8 hours (95% CI, 8.3-9.3) in postoperative length of stay but only 1.2 hours (95% CI, 0.77-1.6) later time of discharge. For prostatectomies, the estimated difference is a decrease of 6.9 hours (95% CI, 6.4-7.4) for postoperative length of stay and 2.5 hours (95% CI, 2.0-3.0) later discharge time.

CONCLUSIONS

Postoperative length of stay is a poor outcome measure in a short-stay setting. When assessing rapidity of recovery for single overnight stay patients, we advocate the use of discharge time with adjustment for surgery start time. The effect of surgery start time on both postoperative length of stay and discharge time should be investigated to ascertain which is best to assess rapidity of recovery in other ambulatory care settings where recovery involves a single overnight stay.

Safety and Cost-Effectiveness of Outpatient Unicompartmental Knee Arthroplasty in the Ambulatory Surgery Center: A Matched Cohort Study

Using an age- and comorbidity-matched cohort, we compared patients who underwent unicompartmental knee arthroplasty in an ambulatory surgery center with those who underwent the procedure in a traditional hospital inpatient setting. Postoperatively, the ambulatory surgery center cohort had fewer major complications than the inpatient cohort. No ambulatory surgery center patients required acute hospital admission and none had major complications. Four major complications occurred in the inpatient cohort. There was no difference in complication rates. Our results suggest that outpatient unicompartmental knee arthroplasty in a freestanding ambulatory surgery center is a safe and reasonable alternative to the traditional inpatient hospital setting.

A Safety and Cost Analysis of Outpatient Versus Inpatient Hindfoot Fusion Surgery

Background. Hindfoot fusion procedures are increasingly being performed in the outpatient setting. However, the cost savings of these procedures compared with the risks and benefits has not been clearly investigated. The objective of this study was to compare patient characteristics, costs, and short-term complications between inpatient and outpatient procedures. Methods. This was a retrospective review of all patients who underwent inpatient and outpatient hindfoot fusion procedures by a single surgeon, at 1 academic institution, from 2013 to 2017. Data collected included demographics, operative variables, comorbidities, complications, costs, and subsequent reencounters. Results. Of 124 procedures, 34 were inpatient and 90 were outpatient. Between procedural settings, with the numbers available, there was no significant increase in complication rate or frequency of reencounters within 90 days. There were no significant differences in the number of patients with reencounters related to the index procedure within 90 days (P = .43). There were 30 reencounters within 90 days after outpatient surgery versus 4 after inpatient surgery (P = .05). The total number of emergency room visits in the outpatient group within 90 days was significantly higher compared with the inpatient group (P = .04). The average cost for outpatient procedures was US$4159 less than inpatient procedures (P < .0001). Conclusion. Outpatient hindfoot fusion may be a safe alternative to inpatient surgery, with significant overall cost savings and similar rate of short-term complications. On the basis of these findings, we believe that outpatient management is preferable for the majority of patients, but further investigation is warranted. Levels of Evidence: Level III.

Incidence and safety profile of outpatient unicompartmental knee arthroplasty

BACKGROUND

Outpatient surgery is an increasingly attractive option for patients undergoing procedures with established, acceptable risk profiles. Benefits of outpatient surgery include cost savings, enhanced patient experience and improved resource allocation at busy hospitals. The purpose of this study was to compare 90-day complication and readmission rates for patients undergoing unicompartmental knee arthroplasty (UKA) in the outpatient as opposed to the inpatient setting.

METHODS

Patients who underwent UKA (CPT code 27446) between 2007 and 2016 were retrospectively selected from a national private insurance database. Patients were defined as ambulatory if their coded location of procedure was in an ambulatory surgery center or as an in-hospital outpatient. Postoperative complications were identified using the Reportable Center for Medicare Services (CMS) Complication Measures. Risks of complications were compared between the inpatient and outpatient cohorts using multivariate logistic regression controlling for age, gender, and comorbidities.

RESULTS

2600 patients undergoing ambulatory UKA and 5084 patients undergoing inpatient UKA were identified. The percentage of UKA procedures performed on an outpatient basis significantly increased over the course of the study (14.5% to 58.1%, p < 0.001). After adjusting for age, gender, and comorbidities, ambulatory surgery was found to be associated with a decreased risk of postoperative transfusion (OR 0.28; p < 0.001) and pneumonia (OR 0.23; p = 0.008) and there was a trend towards decreased 90-day readmission risk (OR = 0.83; p = 0.062).

CONCLUSION

Ambulatory discharge following UKA is increasing in popularity, does not increase risk for perioperative complications or readmission, and may even portend a safer post-operative course.

Optimizing Outpatient Total Ankle Replacement from Clinic to Pain Management

Outpatient total ankle arthroplasty is a potential significant source of cost savings. The ability to institute an effective outpatient total ankle program depends on appropriate patient selection, surgeon experience with total ankle replacement, addressing preoperative patient expectations, the involvement of an experienced multidisciplinary care team including experienced anesthesiologists, nurse navigators, recovery room nursing staff and physical therapists, and most importantly, such a program requires complete institutional logistical support.

Unicompartmental knee arthroplasty: Current indications, technical issues and results

An age younger than 60 years, a body weight of 180 lb (82 kg) or more, performing heavy work, having chondrocalcinosis and having exposed bone in the patellofemoral (PF) joint are not contraindications for unicompartmental knee arthroplasty (UKA).Severe wear of the lateral facet of the PF joint with bone loss and grooving is a contraindication for UKA.Medial UKA should only be performed in cases of severe osteoarthritis (OA) as shown in pre-operative X-rays, with medial bone-on-bone contact and a medial/lateral ratio of < 20%.The post-operative results of UKA are generally good. Medium-term and long-term studies have reported acceptable results at 10 years, with implant survival greater than 95% for UKAs performed for medial OA or osteonecrosis and for lateral UKA, especially when fixed-bearing implants are used.When all implant-related re-operations are considered, the 10-year survival rate is 94%, and the 15-year survival rate is 91%.Aseptic loosening is the principal failure mechanism in the first few years in mobile-bearing implants, whereas OA progression causes most failures in later years in fixed-bearing implants.The overall complication rate and the comprehensive re-operation rate are comparable in both mobile bearings and fixed bearings.The survival likelihood of the all-polyethylene UKA implant is similar to that of metal-backed modular designs for UKA.Notable cost savings of approximately 50% can be achieved with an outpatient UKA surgery protocol. Outpatient surgery for UKA is efficacious and safe, with satisfactory clinical results thus far. Cite this article: EFORT Open Rev 2018;3:363-373. DOI: 10.1302/2058-5241.3.170048.

Medication, equipment, and supply costs for common interventions providing extended post-surgical analgesia following total knee arthroplasty in US hospitals

AIMS

To estimate the cost to hospitals of materials (i.e. medications, equipment, and supplies) required to administer common interventions for post-surgical analgesia after total knee arthroplasty (TKA), including single-injection peripheral nerve block (sPNB), continuous peripheral nerve block (cPNB), periarticular infiltration of multi-drug cocktails, continuous epidural analgesia, intravenous patient-controlled analgesia (IV PCA), and local infiltration of bupivacaine liposome injectable suspension (BLIS).

MATERIALS AND METHODS

This analysis was conducted using a mixed methods approach combining published literature, publicly available data sources, and administrative data, to first identify the materials required to administer these interventions, and then estimate the cost to the hospital of those materials. Medication costs were estimated primarily using the Wholesale Acquisition Costs (WAC), the cost of reusable equipment was obtained from published sources, and costs for disposable supplies were obtained from the US Government Services Administration (GSA) database. Where uncertainty existed about the technique used when administering these interventions, costs were calculated for multiple scenarios reflecting different assumptions.

RESULTS

The total cost of materials (i.e. medications, equipment, and supplies) required to provide post-surgical analgesia was $41.88 for sPNB with bupivacaine; $756.57 for cFNB with ropivacaine; $16.38 for periarticular infiltration with bupivacaine, morphine, methylprednisolone, and cefuroxime; $453.84 for continuous epidural analgesia with fentanyl and ropivacaine; $178.94 for IV PCA with morphine; and $319.00 for BLIS.

LIMITATIONS

This analysis did not consider the cost of healthcare providers required to administer these interventions. In addition, this analysis focused on the cost of materials and, therefore, did not consider aspects of relative efficacy or safety, or how the choice of intervention for post-surgical analgesia might impact outcomes such as length of stay, re-admissions, discharge status, adverse events, or total hospitalization costs.

CONCLUSIONS

This study provided an estimate of the costs to hospitals for materials required to administer commonly used interventions for post-surgical analgesia after TKA.