key: cord-0829935-qxi51sa8
authors: Cannon, Dylan; Lewis, Steven; Garcia, Jose; Watkins, Adam; Rodriguez, Hugo; Levy, Jonathan C.
title: A Comparison of Patient Same Day Discharge (SDD) Selection Following Shoulder Arthroplasty Before and After the COVID-19 Pandemic.
date: 2022-04-09
journal: Semin Arthroplasty
DOI: 10.1053/j.sart.2022.02.011
sha: ecc850a767251b1a621ff3601bd4ce78b18ca484
doc_id: 829935
cord_uid: qxi51sa8

INTRODUCTION: Early discharge has been a target of cost control efforts given the growing demand for joint replacement surgery. Select patients are given the choice for same day discharge (SDD) or overnight stay following shoulder arthroplasty. The COVID-19 pandemic changed patient perspectives regarding hospital visitation and admission. The purpose of this study was to determine if the COVID-19 pandemic impacted the utilization of SDD following shoulder arthroplasty. We hypothesize that patients undergoing shoulder arthroplasty after the start of the COVID-19 pandemic will have higher rates of SDD. METHODS: A retrospective continuous review was performed on 370 patients who underwent a primary anatomic (TSA) or reverse shoulder arthroplasty (RSA) between August 2019 and December 2020 by a single surgeon. This group of patients represent the 185 arthroplasty cases completed before the COVID-19 pandemic, and the first 185 patients after the start of the pandemic. April 1, 2020 was chosen as the cutoff for pre-COVID patients, as this represents the date a statewide ban on elective surgery was declared. All patients were counseled preoperatively regarding SDD and given the choice to stay overnight, unless medically contraindicated. Demographics, medical history, length of stay, 30 and 90-day readmissions, and 90-day emergency room (ER) and urgent care visits were obtained from medical records and compared. Two-tailed student t-tests, chi-square tests, and Fischer’s Exact were performed where appropriate. RESULTS: The two groups were similar in age, BMI, gender distribution, and Outpatient Arthroplasty Risk Assessment (OARA) score. During the collection period, there were more anatomic shoulder arthroplasties performed after (54%) than before (44%) the COVID-19 pandemic (p=0.029). Patients treated after the start of the COVID-19 pandemic were almost 3 times more likely to have a SDD (p<0.001), with 85.4% (158/185) of patients being discharged the same day following COVID-19, compared to 34.6% (64/185) before COVID-19. Discharge Disposition (location of discharge) was significantly different, as 99% (183/185) of patients undergoing surgery after the start of the COVID-19 pandemic were discharged home, compared to 94% (174/185) of patients before COVID-19. There was no difference in 30-day readmissions, 90-day readmissions, and 90-day (ER) and urgent care visits between the two groups. CONCLUSION: Our study suggests that the COVID-19 pandemic has dramatically impacted patient choices for SDD within a single surgeon’s practice, with nearly 3 times as many patients electing for SDD. Readmissions and ER visits were similar, indicating that SDD remains a safe alternative for patients following TSA and RSA.

pandemic (p=0.029). Patients treated after the start of the COVID-19 pandemic were almost 3 24 times more likely to have a SDD (p<0.001), with 85.4% (158/185) of patients being discharged 25 the same day following COVID-19, compared to 34.6% (64/185) before COVID-19. Discharge 26 Disposition (location of discharge) was significantly different, as 99% (183/185) of patients 27 undergoing surgery after the start of the COVID-19 pandemic were discharged home, compared 28 to 94% (174/185) of patients before COVID-19. There was no difference in 30-day 29 readmissions, 90-day readmissions, and 90-day (ER) and urgent care visits between the two 30 groups. 31

Our study suggests that the COVID-19 pandemic has dramatically impacted 32 patient choices for SDD within a single surgeon's practice, with nearly 3 times as many patients 33 electing for SDD. Readmissions and ER visits were similar, indicating that SDD remains a safe 34 alternative for patients following TSA and RSA. Early discharge has been a target of cost control efforts in hospitals for many different 38 procedures. Shoulder arthroplasty is an effective procedure for pain relief and improved function 39 in patients with a wide variety of shoulder pathology 24 . Its use has risen dramatically over the 40 past several decades, with a 339% increase between 1993 and 2008 16,17,28 . Given the growing 41 demand for shoulder replacement surgery and the pressure on providing adequate beds in the 42 hospital, an emphasis has been placed on early discharge for shoulder arthroplasty patients 19 . 43

Earlier discharge in arthroplasty patients has been shown to be safe and effective, with a decrease 44 in 30-day complication and readmission rates with a shorter hospital length of stay 4,27,30 . 45 46 J o u r n a l P r e -p r o o f Select patients are often given the choice for same day discharge (SDD) or overnight stay 47 following shoulder arthroplasty. A recent study by Grewal et al has shown that patient-specific 48 non-medical factors such as anxiety regarding recovery, distance from home to hospital, and 49 previous experiences play an important role when deciding between SDD and an overnight 50 hospital stay 14 . This study was conducted prior to the COVID-19 pandemic. The COVID-19 51 pandemic likely changed patient perspectives regarding hospital visitation and admission, with 52 many patients choosing to avoid the hospital as much as possible 9,15 . Hip and knee arthroplasty 53 has already seen a dramatic shift towards outpatient surgery, as both procedures are no longer on 54 the CMS inpatient only list and are listed on the ambulatory surgery center (ASC) covered 55 procedures list. Yet, the medical risk threshold for SDD after lower extremity arthroplasty has 56 been shown to be higher than for shoulder arthroplasty 25 . With a better understanding of the 57 medical risks associated SDD after shoulder arthroplasty, shoulder surgeons were likely prepared 58 for the demand for SDD when the COVID-19 pandemic arrived. 59

The purpose of this study was to examine the impact of the COVID-19 pandemic on the 60 utilization of SDD following shoulder arthroplasty. We hypothesize that patients undergoing 61 shoulder arthroplasty after the beginning of the COVID-19 pandemic will have a higher rate of 62 SDD. We also hypothesize that SDD will continue to be a safe alternative for shoulder 63 arthroplasty patients. 64

A retrospective continuous review was performed on 370 patients who underwent a primary 66 anatomic or reverse shoulder arthroplasty between August 2019 and December 2020. A query of 67 our institution's shoulder and elbow repository found that 185 arthroplasty cases were completed 68 from the beginning of the COVID-19 pandemic to the end of year 2020, and 185 cases were 69 completed from August 2019 to the beginning of the pandemic. All cases were performed at a 70 single hospital, and no cases were performed in an ambulatory surgery center during this 71 collection period. This cohort represents a consecutive series of all shoulder arthroplasty cases 72 performed by a single high-volume shoulder and elbow fellowship trained surgeon during this 73 timeframe. All 370 patients had complete hospital records, and were thus all included in the 74 study. April 1, 2020 was chosen as the cutoff for pre-COVID patients, as this represents the date 75 that a statewide ban on elective surgery was declared. All arthroplasties completed after April 1, 76 2020 were considered to be post-COVID. As part of the surgeon's standard practice, following 77 medical optimization by a primary care physician, all patients were counseled during a 78 preoperative appointment regarding SDD and given the choice to remain in the hospital 79 overnight. All patients received the same postoperative rehabilitation protocol, consisting of a 80 shoulder immobilizer and patient-directed pendulum exercise was used in all patients. The two groups were similar in age, BMI, gender distribution, and preoperative medical risk 93 assessment using the Outpatient Arthroplasty Risk Assessment (OARA) score (Table I) (Table 2) . 105

The COVID-19 pandemic resulted in a change in patient attitudes towards hospital visitation and 107 admission, with both patients and surgeons looking for alternatives to hospital admission 9,15 . 108

Results of this study suggest a similar attitude has occurred related to shoulder arthroplasty, as 109 the COVID-19 pandemic resulted in a dramatic shift towards same-day discharge (SDD) 110 following shoulder arthroplasty with no difference in readmission, urgent care or emergency 111 room visits. to have surgery during the COVID-19 pandemic. 137 SDD after shoulder arthroplasty has seen a significant increase in recent years 1,4,7,18 . Given 139 efforts to reduce healthcare costs via early discharge, it is no surprise that there has been a push 140 to increase the amount of same day discharges amongst surgical patients 8 . There is still some 141 hesitancy among providers to offer SDD to certain high-risk patients, especially in shoulder 142 arthroplasty 29 . Despite the SDD rate being significantly higher after the start of the pandemic, 143 complications amongst SDD discharge patients observed in our study were no different. The 144

incidence of 30 and 90-day hospital readmissions and 90-day emergency room and urgent care 145 visits were similar between the pre-COVID and post-COVID groups. This finding further 146 supports the role of same day discharge following shoulder arthroplasty as a safe and reasonable 147 option. 148

Our study is not without limitations. Data was collected from a single, high-volume shoulder 150 arthroplasty institution; thus, the results of this study may not be extrapolated to surgeons with 151 lower-volume experience or varying discharge protocols. The specific reasons that a patient 152 chose for SDD were not reported, and it should not be assumed that the COVID-19 pandemic 153 was the only factor which influenced the patient. We did not investigate non-medical factors 154 such as geographic distance from the hospital or previous experience, which has been previously 155 shown by Grewal J o u r n a l P r e -p r o o f 

of stay despite patients with more comorbidities

Day case vs inpatient total 187 shoulder arthroplasty: A retrospective cohort study and cost-effectiveness analysis

Neer Award 2016: Outpatient total 190 shoulder arthroplasty in an ambulatory surgery center is a safe alternative to inpatient total 191 shoulder arthroplasty in a hospital: a matched cohort study

Is 194 outpatient shoulder arthroplasty safe? A systematic review and meta-analysis

Clinical and cost implications of inpatient 197 versus outpatient orthopedic surgeries: A systematic review of the published literature

Avoidance of Medical Care Because of COVID-19-Related Concerns -United States

Outpatient vs. 204 inpatient reverse total shoulder arthroplasty: outcomes and complications

Identifying 207 appropriate candidates for ambulatory outpatient shoulder arthroplasty: validation of a 208 patient selection algorithm

Patient Selection for Outpatient Shoulder Arthroplasty: A Risk Prediction Tool

Short 214 stay after shoulder arthroplasty does not increase 90-day readmissions in Medicare 215 patients compared with privately insured patients

Does knowledge of medical risk influence 218 patient decision for same day discharge following primary shoulder arthroplasty: a 219 randomized control trial

Barriers to 222 seeking emergency care during the COVID-19 pandemic may lead to higher morbidity 223 and mortality -A retrospective study from a Swiss university hospital

The contribution of reverse shoulder arthroplasty to utilization of 226 primary shoulder arthroplasty

the United States

Same-day 232 discharge is not inferior to longer length of in-hospital stay for 90-day readmissions 233 following shoulder arthroplasty

A Systematic Review of Criteria-Led Patient Discharge

Safety and 238 patient satisfaction of outpatient shoulder arthroplasty

Readmission after shoulder arthroplasty

Safe Selection 243 of Outpatient Joint Arthroplasty Patients With Medical Risk Stratification: the

Arthroplasty Risk Assessment Score

Delayed 247 hospital discharge after total shoulder arthroplasty: why, and who is at risk? JSES Open 248

Functional outcome after shoulder arthroplasty for primary 250 osteoarthritis: A multicenter study

Determining the 253 validity of the Outpatient Arthroplasty Risk Assessment (OARA) tool for identifying 254 patients for safe same-day discharge after primary shoulder arthroplasty

Determining the 257 validity of the Outpatient Arthroplasty Risk Assessment (OARA) tool for identifying 258 patients for safe same-day discharge after primary shoulder arthroplasty

Trends in 261 Length of Stay and 30-Day Complications After Total Knee Arthroplasty: An Analysis 262

National utilization of 264 reverse total shoulder arthroplasty in the United States

The 267 feasibility of outpatient shoulder arthroplasty: Risk stratification and predictive probability 268 modeling

Hospital discharge 270 within 2 days following total hip or knee arthroplasty does not increase major

with more RSA patients in the post-COVID group. This could have an influence on the data, as 163 RSA is typically performed in patients with more severe shoulder disease and higher 164 comorbidities 2,23 . However, Outpatient Arthroplasty Risk Assessment (OARA) scores were 165 similar between the two groups, suggesting similar patient comorbid medical risks. 166

The COVID-19 pandemic has dramatically impacted patient choices for SDD within a single 168 surgeon's practice, with nearly 3 times as many patients electing for SDD. Readmissions and ER 169 visits were similar, indicating that SDD remains a safe alternative for patients following 170 anatomic and reverse shoulder arthroplasty.