Outpatient shoulder arthroplasty rates increase since removal from CMS inpatient-only list
Key takeaways:
- The percent of outpatient total shoulder arthroplasties performed has grown from 2019 to 2022.
- Researchers found similar 90-day complications, readmissions and mortality between outpatients and inpatients.
According to published results, the proportion of outpatient total shoulder arthroplasty procedures has grown from 22% in the first quarter of 2021, when TSA was removed from the CMS inpatient-only list, to 38% in the first quarter of 2022.
Researchers from the Avant-Garde Health and Codman Shoulder Society Value-Based Care Group used Medicare fee-for-service claims to analyze the rates of 14,540 outpatient TSA vs. 40,576 inpatient TSA procedures from 2019 to 2022. They also compared 90-day postoperative complications, all-cause readmissions and mortality between the cohorts.
According to the study, researchers excluded data from the second quarter of 2020 to the fourth quarter of 2020 to reduce the impact and selection bias of the COVID-19 pandemic.
Overall, the proportion of outpatient TSA increased from 3% (n = 619) in the first quarter of 2019 to 22% (n =3,456) in the first quarter of 2021 to 38% (n = 6,778) in the first quarter of 2022.
After matching 12,703 outpatients to inpatients, researchers found congruent rates of 90-day postoperative outcomes. Matched outpatients had an overall complication rate of 1.4% (n = 178), a hospital readmission rate of 3.8% (n = 488) and a mortality rate of 0.3% (n = 34). Similarly, matched inpatients had an overall complication rate of 1.4% (n = 174), a hospital readmission rate of 3.8% (n = 480) and a mortality rate of 0.3% (n = 32).
“We found that by the end of the first quarter of 2022, TSA volume had been steadily increasing over time to 38% in the Medicare population, especially after CMS approval as an outpatient procedure in January 2021,” researchers wrote in the study. “From a clinician’s perspective, what matters is to find a practical way to assign individual patients to the right care setting,” they wrote.
Perspective
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Orthopedic procedures continue to migrate to the outpatient environment. This trend is based on multiple factors including better patient risk stratification, improved surgical techniques, perioperative care strategies and postoperative pain protocols, as well as improved outpatient rehabilitation and care coordination. Hip and knee replacement has been successfully migrated to the outpatient environment; why not shoulder replacement? Studies have demonstrated that appropriately selected patients demonstrate high levels of patient satisfaction with no increased risk for complication or readmission when comparing true same-day outpatient shoulder arthroplasty to those with overnight hospital stays. In addition, perioperative complication rates of shoulder arthroplasty, such as deep vein thrombosis, are lower than those in lower extremity surgery. Lastly, patients do not have mobility issues with upper extremity surgery, allowing improved safety and function in the home environment. With our health system in financial distress, further migration to ASCs is the next logical step for CMS. ASCs offer improved quality, higher patient satisfaction and lower cost, meeting the needs of our patients. Let’s hope they make the right decision.
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