key: cord-0970846-ka5act1q
authors: Seetharam, Abhijit; Ghosh, Priyanka; Prado, Ruben; Badman, Brian L.
title: Trends in Outpatient Shoulder Arthroplasty during the COVID-19 era: Increased Proportion of Outpatient Cases with Decrease in 90-day Readmissions
date: 2022-01-26
journal: J Shoulder Elbow Surg
DOI: 10.1016/j.jse.2021.12.031
sha: 0aea4d2156443e86d32a7997315e7381f042bd99
doc_id: 970846
cord_uid: ka5act1q

Background The COVID-19 pandemic has placed increased burden on healthcare resources, with hospitals around the globe cancelling or reducing most elective surgical cases during the initial period of the pandemic. Simultaneously, there has been an increased interest in performing outpatient total joint arthroplasty in an efficient manner while maintaining patient safety. The purpose of this study is to investigate trends in total shoulder arthroplasty during the COVID-19 era with respect to outpatient surgery and postoperative complications. Methods After approval from our Institution Review Board (IRB), a retrospective chart review was performed of all primary anatomic and reverse total shoulder arthroplasties at our health institution over a 3 year period (January 2018 – January 2021). All cases done prior to March 2020 were considered the “pre-COVID era” cohort. All cases after March 2020 were in the “COVID-19 era” cohort. Patient demographic and medical comorbidities were also collected to appropriately match patients from the two cohorts. Outcomes measured included patient encounter (outpatient versus inpatient), total length of stay, and 90 day complications. Results A total of 567 total shoulder arthroplasties met the inclusion criteria. There were 270 shoulder arthroplasty cases during the COVID-19 era, and 297 cases during the examined pre-COVID era. There were no significant differences in BMI, ASA score, smoking status, or distribution of pertinent medical comorbidities between the two examined cohorts. During the COVID-19 era, 31.8% of shoulder arthroplasties were performed in the outpatient setting. This was significantly higher than in the pre-COVID era, with only 4.5% of cases done in an outpatient setting (p < 0.0001). Average length of stay was significantly reduced in the COVID-19 era cohort (0.81 versus 1.45 days, p<0.0001). There was a significant decrease in 90-day readmissions during the COVID-19 era. 90 day ER visits, 90 day VTE, or 90 day postoperative infection were not significantly different between the two cohorts. Conclusion We found a significant increase in the number of outpatient shoulder arthroplasty cases being done at our health institution during the COVID-19 era, likely due to a multitude of factors including improved perioperative patient management and increased hospital burden from the COVID-19 pandemic. This increase in outpatient cases was associated with a significant reduction in average hospital length of stay and decrease in 90 day readmissions compared to the pre-COVID era. The data suggest that outpatient total shoulder arthroplasty can be performed in a safe and efficient manner in the appropriate patient cohort. Level of Evidence Level III; Retrospective Case Control Design; Epidemiology Study

Running Title: Outpatient Shoulder Arthroplasty during COVID-19 era 4 5 6

Background 7

The COVID-19 pandemic has placed increased burden on healthcare resources, with hospitals 8 around the globe cancelling or reducing most elective surgical cases during the initial period of 9 the pandemic. Simultaneously, there has been an increased interest in performing outpatient total 10 joint arthroplasty in an efficient manner while maintaining patient safety. The purpose of this 11 study is to investigate trends in total shoulder arthroplasty during the COVID-19 era with respect 12 to outpatient surgery and postoperative complications. 13

After approval from our Institution Review Board (IRB), a retrospective chart review was 15 performed of all primary anatomic and reverse total shoulder arthroplasties at our health 16 institution over a 3 year period (January 2018 -January 2021). All cases done prior to March 17 2020 were considered the "pre-COVID era" cohort. All cases after March 2020 were in the 18 "COVID-19 era" cohort. Patient demographic and medical comorbidities were also collected to 19 appropriately match patients from the two cohorts. Outcomes measured included patient 20 encounter (outpatient versus inpatient), total length of stay, and 90 day complications. 21

A total of 567 total shoulder arthroplasties met the inclusion criteria. There were 270 shoulder 23 pertinent medical comorbidities between the two examined cohorts. During the COVID-19 era, 26 31.8% of shoulder arthroplasties were performed in the outpatient setting. This was significantly 27 higher than in the pre-COVID era, with only 4.5% of cases done in an outpatient setting (p < 28 0.0001). Average length of stay was significantly reduced in the COVID-19 era cohort (0.81 29 versus 1.45 days, p<0.0001). There was a significant decrease in 90-day readmissions during the 30 COVID-19 era. 90 day ER visits, 90 day VTE, or 90 day postoperative infection were not 31 significantly different between the two cohorts. 32

We found a significant increase in the number of outpatient shoulder arthroplasty cases being 34 done at our health institution during the COVID-19 era, likely due to a multitude of factors 35

including improved perioperative patient management and increased hospital burden from the 36 COVID-19 pandemic. This increase in outpatient cases was associated with a significant 37 reduction in average hospital length of stay and decrease in 90 day readmissions compared to the 38 pre-COVID era. The data suggest that outpatient total shoulder arthroplasty can be performed in 39 a safe and efficient manner in the appropriate patient cohort. Total shoulder arthroplasty (TSA) is an effective treatment strategy for patients with 47 TSA surgeries being done in the United States has continued to increase, with some projections 50 that the growth rate may exceed those of hip and knee arthroplasty. 10, 16, 22 There has also been an 51 increased interest in the safety and efficacy of outpatient joint arthroplasty. Improvements in 52 preoperative medical optimization, perioperative analgesia, and surgical techniques have reduced 53 average length of stay, blood loss, and overall complication rates after total joint arthroplasty. 1, 9, 54 11, 23, 26 Furthermore, thru improvements in regional anesthesia, pain control has been greatly 55 improved leading to the overall increase in migration of TSA to an outpatient setting. The recent COVID-19 pandemic has placed an unprecedented burden on hospital systems 63 across the globe. The initial response by many governments was to pause all elective surgeries. 64

When elective surgeries were resumed, many hospitals were at or near full capacity due to 65 patients admitted with COVID-19. 27, 28 The purpose of this study was to investigate trends in 66 total shoulder arthroplasty before and during the COVID-19 pandemic. With increased inpatient 67 burden, we hypothesized that there would be an increase in outpatient TSA during the COVID-68 19 era. Additionally, we sought to compare complication rates between the two time periods to 69 determine if increased outpatient TSA was associated with significant changes in postoperative 70 complications such as emergency room visits, readmission, repeat surgery, and venous 71 thromboembolism. 72 J o u r n a l P r e -p r o o f

The study design was a retrospective cohort study. After obtaining approval from our 75

Institutional Review Board (IRB), a retrospective chart review was performed. All patients who 76 underwent shoulder arthroplasty were identified in our institutional electronic medical record 77 (EMR) from January 1, 2018 to January 1, 2021. Inclusion criteria were patients undergoing 78 elective, primary total shoulder arthroplasty for osteoarthritis or rotator cuff arthropathy. Patients 79 with revision arthroplasty, hemiarthroplasty, or arthroplasty done for fractures were excluded 80 from the study. The final patient cohort included shoulder arthroplasties from 17 surgeons and 8 81 hospitals or surgery centers. 82

Patients who met inclusion criteria were then separated into two groups based on date of 83 surgery. Patients who underwent surgery after March 2020 were included in the "COVID-19 84 era" group and patients who underwent surgery before March 2020 were considered the "pre-85 COVID-19 era" group. Patients between both groups were then matched based on age, sex, body 86 mass index (BMI), American Society of Anesthesiologist (ASA) score, type of arthroplasty 87 (anatomic versus reverse), use of regional anesthetic, smoking status, and other key medical 88 comorbidities (Table 1) patients were in the "COVID-19 era" cohort and 297 patients were in the "pre-COVID" cohort. 106

There was no significant difference in average patient age, gender proportion, BMI, patients with 107 ASA score  3, diabetes, smokers, and other key medical comorbidities between the two groups 108 (Table 1) . There was a significant increase in the proportion of outpatient TSA cases during the 109 COVID-19 era compared to the pre-COVID-19 era (31.9% versus 6.1%). There was no 110 significant difference in type of arthroplasty performed between the two groups. As 111 hypothesized, there were significantly more inpatient cases performed in the pre-COVID-19 era 112 than the COVID-19 era. There was no significant difference in the type of anesthesia 113 administered between patient cohorts (Table 2) . 93% (526/567) of patients had minimum 90-day 114 follow-up for this study. 115

With regards to outcomes examined, there was a statistically significant reduction in 116 average length of hospital stay in the COVID-19 era (0.8 days vs 1.4 days, p < 0.0001). There 117 was a significant decrease in number of surgery-related 90 day readmissions during the COVID-118 infections seen between the two cohorts, although these differences were not statistically 120 significant (Table 3) . 121

A subgroup analysis of the COVID-19 era was also performed to better understand 122 demographic and complication rates within this cohort. Patients undergoing inpatient surgery did 123 have statistically significant increased age (70.6 years versus 64.1 years, p < 0.001), but there 124 was no difference observed in other variables including BMI, ASA score, diabetes, and smoking. 125

With respect to complications, there was no significant difference in the rate of studied 126 complications between the inpatient and outpatient groups within the COVID-19 era cohort 127 (Table 4) . 128

129

The COVID-19 pandemic has placed an increased burden on hospital inpatient capacity, 131 from the lack of hospital beds to the overall reduction in elective surgeries. Once guidelines were 132 laxed and elective surgeries were allowed to be resumed, many surgeons and systems began to 133 transition to fewer admissions and more surgeries done as an outpatient. The pandemic 134 essentially coincided with a growing trend to do shoulder replacement as an outpatient especially 135 with increasing evidence of its safety and efficacy. The objective of our study was, therefore, to 136 investigate trends in outpatient shoulder arthroplasty before and during the COVID-19 pandemic 137 and subsequent short-term adverse postoperative events at our institution. Our hypotheses were 138 confirmed as we found a significant increase in the proportion of outpatient TSA cases 139 performed during the COVID-19 era with fewer 90-day complications when compared to TSA 140 cases done prior to the COVID-19 pandemic. We also found a significant reduction in average 141 length of hospital stay between the two time periods examined that correlated with an increased 142 proportion of outpatient shoulder arthroplasty. visits for matters unrelated to COVID-19 since the pandemic began, likely due to initial mobility 161 restrictions and fear of contagion 3, 13 . However, the greatest reduction in ER visits was seen 162 during the early portion of the pandemic 14 when most elective surgeries were also paused by 163 government mandate, making it unclear how big a confounding factor this would be for our 164 J o u r n a l P r e -p r o o f particular study. Our results, therefore, with fewer ER visits and readmissions could be 165 attributable to the initial fear of going to the hospital. 166

There is sufficient data in the literature to suggest that outpatient TSA is safe, cost-167 effective, and efficient for both surgeons and patients 6, 19 . However, appropriate patient selection 168 is still important to ensure low peri-operative complication risk. Prior research has shown that 169 perioperative factors are key predictors of length of stay (LOS) after shoulder arthroplasty. 170

Matsen et al 20 found a 73% increase in LOS in patients with a Charlson Comorbidity Index 171 greater than 1. Our two patient cohorts were separated based on date of surgery but matched to 172 have no difference in age, sex, BMI, and other comorbidities. However, when our patient cohort 173 was separated based solely on outpatient and inpatient TSA regardless of time period, patients 174 who underwent outpatient TSA had, on average, younger age, lower BMI, and lower ASA 175 scores. These differences, however, were not statistically significant. There were similar rates of 176 smoking, diabetes, and other comorbidities between outpatient and inpatient cohorts. When 177 further analyzed as a COVID-19 era subgroup, we did note a statistically significant younger age 178 in patients undergoing outpatient arthroplasty. However, there was still no difference noted in 179 other demographic and comorbidity data collected. There was also no significant differences in 180 measured complication rates between the outpatient and inpatient groups in our subgroup 181 analysis. While the results of our study suggest that increased outpatient TSA did not lead to 182 increased 90-day complications, it is still important to evaluate each patient independently to 183 determine the appropriateness of outpatient surgery. 184

This study does have limitations that are important to note. First, this was a retrospective 185 cohort study and therefore has limitations that are common to all retrospective studies. As an 186 observational study, no inference about causation can be made and the findings should be interpreted accordingly. Additionally, we were able to measure short-term postoperative 188 complications, but due to the nature of our institutional health system, we did not have consistent 189 prospective patient outcomes to report, which may have enhanced the conclusions drawn from 190 this study. Similarly, we were unable to study functional outcomes, patient satisfaction, or 191 compare costs between our two cohorts. Our primary outcomes of interest were proportion of 192 outpatient surgeries and length of stay. However, our secondary outcomes including 

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