Vajapey Sravya P, Contreras Erik S, Neviaser Andrew S, Bishop Julie Y, Cvetanovich Gregory L
Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio.
JBJS Rev. 2021 May 6;9(5):01874474-202105000-00002. doi: e20.00189.
Orthopaedic surgical procedures are increasingly being performed in outpatient settings. The drive for cost reduction without compromising patient safety and outcomes has increased interest in outpatient total shoulder arthroplasty (TSA). The primary aim of this study was to perform a review of the evidence regarding the outcomes and cost-effectiveness of outpatient TSA.
A search of the PubMed, Embase, and Cochrane Library databases was performed using several keywords: "outpatient," "shoulder replacement," "ambulatory," "day case," "day-case," "shoulder arthroplasty," "same day," and "shoulder surgery." Studies that were published from May 2010 to May 2020 in the English language were considered. Research design, questions, and outcomes were recorded for each study. Qualitative and quantitative pooled analysis was performed on the data where appropriate.
Twenty studies met the inclusion criteria. Six retrospective studies compared complication rates between inpatient and outpatient cohorts and found no significant differences. Four studies found that the complication rate was lower in the outpatient cohort compared with the inpatient cohort. In a pooled analysis, the readmission rate after outpatient TSA was significantly lower than the readmission rate after inpatient TSA at 30 days (0.65% vs. 0.95%) and 90 days (2.03% vs. 2.87%) postoperatively (p < 0.05 for both). Four studies evaluated the cost of outpatient TSA in comparison with inpatient TSA. All of these studies found that TSA at an ambulatory surgery center was significantly less costly than TSA at an inpatient facility, both for the health-care system and for the patient. Patient selection for outpatient TSA may depend on several important factors, including the presence or absence of diabetes, chronic obstructive pulmonary disease, chronic kidney disease, congestive heart failure, poor functional status, higher American Society of Anesthesiologists class, chronic narcotic use, higher body mass index, and older age.
Our results show that patient selection is the most critical factor that predicts the success of outpatient TSA. While outpatient TSA is significantly less costly than inpatient TSA, patients undergoing outpatient TSA are more likely to be healthier than patients undergoing inpatient TSA. More high-quality long-term studies are needed to add to this body of evidence.
Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
骨科手术越来越多地在门诊环境中进行。在不影响患者安全和手术效果的前提下降低成本的需求，增加了人们对门诊全肩关节置换术（TSA）的兴趣。本研究的主要目的是对有关门诊TSA的手术效果和成本效益的证据进行综述。
使用多个关键词在PubMed、Embase和Cochrane图书馆数据库中进行检索：“门诊”“肩关节置换”“非卧床”“日间手术”“日间病例”“肩关节置换术”“同日”和“肩部手术”。纳入2010年5月至2020年5月以英文发表的研究。记录每项研究的研究设计、问题和结果。在适当情况下对数据进行定性和定量汇总分析。
20项研究符合纳入标准。六项回顾性研究比较了住院和门诊队列的并发症发生率，未发现显著差异。四项研究发现门诊队列的并发症发生率低于住院队列。在一项汇总分析中，门诊TSA术后30天（0.65%对0.95%）和90天（2.03%对2.87%）的再入院率显著低于住院TSA术后（两者p<0.05）。四项研究评估了门诊TSA与住院TSA的成本。所有这些研究均发现无论是对医疗系统还是患者而言，门诊手术中心的TSA成本均显著低于住院机构的TSA。门诊TSA的患者选择可能取决于几个重要因素，包括是否患有糖尿病、慢性阻塞性肺疾病、慢性肾病、充血性心力衰竭、功能状态差、美国麻醉医师协会分级较高、长期使用麻醉药品、体重指数较高以及年龄较大。
我们的结果表明，患者选择是预测门诊TSA成功的最关键因素。虽然门诊TSA的成本显著低于住院TSA，但接受门诊TSA的患者可能比接受住院TSA的患者更健康。需要更多高质量的长期研究来补充这一证据。
治疗性四级。有关证据水平的完整描述，请参阅作者指南。
