Trend of ambulatory benign prostatic obstruction surgeries during COVID-19 pandemic.

INTRODUCTION: Benign prostatic obstruction (BPO) is one of the most common causes of male lower urinary tract symptoms. Some institutions routinely perform BPO surgeries in ambulatory setting, while others elect for overnight hospitalization. With the COVID-19 pandemic limiting resources and hospital space for elective surgery, we investigated the time trend of ambulatory BPO procedures performed around the COVID-19 outbreak. METHODS: We identified BPO surgeries from the California State Inpatient and State Ambulatory Surgery Databases between 2018 and 2020. Our primary outcome was the proportion of procedures performed in ambulatory settings with a length of stay of zero days. Univariable and multivariable analyses were performed to analyze factors associated with ambulatory surgery around the COVID-19 outbreak. Spline regression with a knot at the pandemic outbreak was performed to compare time trends pre- and post-pandemic. RESULTS: Among 37,148 patients who underwent BPO procedures, 30,067 (80.9%) were ambulatory. Before COVID-19, 80.1% BPO procedures were performed ambulatory, which increased to 83.4% after COVID-19 outbreak (p < 0.001). In multivariable model, BPO procedures performed after COVID-19 outbreak were 1.26 times more likely to be ambulatory (OR 1.26, 95% CI 1.14-1.40, p < 0.0001). Spline curve analysis indicated significantly different trend of change pre- and post-pandemic (p = 0.006). CONCLUSIONS: We observed a rising trend of BPO surgeries performed in ambulatory setting post-pandemic. It remains to be seen if the observed ambulatory transition remains as we continue to recover from the pandemic.

Geriatric Dermatologic Surgery Part I: Frailty assessment and palliative treatments in the geriatric dermatology population.

Longer life expectancy and increasing keratinocyte carcinoma incidence contribute to an increase in geriatric patients presenting for dermatologic surgery. Unique considerations accompany geriatric patients including goals of care, physiologic changes in medication metabolism, cognitive decline, and frailty. Limited geriatric training in dermatology residency has created a knowledge gap and dermatologic surgeons should be familiar with challenges facing older patients to provide interventions more congruent with goals and avoid overtreatment. Frailty assessments including the Geriatric 8 and Karnofsky Performance Scale are efficient tools to identify patients who are at risk for poor outcomes and complications. When frail patients are identified, goals of care discussions can be aided using structured palliative care frameworks including the 4Ms, REMAP, and Serious Illness Conversation Guide. Most geriatric patients will tolerate standard of care treatments including invasive modalities like Mohs surgery and excision. However, for frail patients, non-standard treatments including topicals, energy-based devices, and intralesional chemotherapy may be appropriate options to limit patient morbidity while offering reasonable disease control.

Geriatric Dermatologic Surgery Part II: Peri and intraoperative considerations in the geriatric dermatologic surgery patient.

Geriatric patients compose a growing proportion of the dermatologic surgical population. Dermatologists and dermatologic surgeons should be cognizant of the unique physiologic considerations that accompany this group to deliver highly effective care. The purpose of this article is to discuss the unique preoperative, intraoperative, and postoperative considerations geriatric patients present with to provide goal-concordant care. Preoperative considerations include medication optimization and anxiolysis. Intraoperative considerations such as fall-risk assessment and prevention, sundowning, familial support, and pharmacologic interactions will be discussed. Lastly, effective methods for optimizing post-operative wound care, home care, and follow up are reviewed.

The development of day surgery in China and the effectiveness and reflection of day surgery in ophthalmology-specialized hospitals.

This survey investigates the development of day surgery in China, and analyzes the national policy support, medical service management model, disease types of day surgery, medical insurance payment methods, and the medical service capacity, efficiency, quality and safety, health economics indicators, and patient satisfaction after the implementation of day surgery in a tertiary eye hospital. After more than 20 years of development, China's day surgery has shown a good development trend. The implementation of day surgery in eye hospitals accounts for more than 70% of elective surgery, and patients, medical institutions, and medical insurance institutions have all achieved good social benefits.

Opioid-free versus opioid-sparing anaesthesia in ambulatory total hip arthroplasty: a randomised controlled trial.

BACKGROUND: Enhanced recovery after surgery pathways are essential for ambulatory surgery. They usually recommend lower intraoperative opioid use to avoid opioid-related adverse effects. This has led to opioid-sparing anaesthesia (OSA) techniques, with the extreme approach of opioid-free anaesthesia (OFA) mostly with dexmedetomidine. As evidence is lacking in day-case primary total hip arthroplasty, this study was performed to assess the potential benefits in postoperative analgesia of OFA over OSA. METHODS: In this single-centre, prospective, triple blind study, we randomly allocated 80 patients undergoing day-case primary THA under general anaesthesia. Patients received a total intravenous anaesthesia with a laryngeal mask and multimodal analgesic regimen with non-opioid analgesics. The OSA group received low dose of sufentanil, and the OFA group received dexmedetomidine The primary outcome was the opioid consumption in the first 24 h in oral morphine equivalents (OME). RESULTS: There was no difference in median cumulative OME consumption at 24 h between the OSA and OFA groups (12 [0-25] mg vs 16 [0-30] mg, respectively; P=0.7). Pain scores were similar and low in both groups with comparable walking recovery time. Adverse events were sparse and equivalent in both groups except for dizziness, which was more frequent in the OSA group (P<0.05). CONCLUSIONS: In day-case total hip arthoplasty under general anaesthesia, opioid-free anaesthesia and opioid-sparing anaesthesia both provide early recovery and effective postoperative pain relief. When compared with opioid-sparing anaesthesia, opioid-free anaesthesia does not decrease opioid consumption in the first 24 h. These findings do not suggest any significant benefit from complete intraoperative avoidance of opioids. CLINICAL TRIAL REGISTRATION: NCT0507270.

From pain level to pain experience: redefining acute pain assessment to enhance understanding of chronic postsurgical pain.

BACKGROUND: Chronic postsurgical pain (CPSP) significantly impairs quality of life and poses a substantial healthcare burden, affecting up to a quarter of patients undergoing surgery. Although acute pain is recognised as a predictor for CPSP development, the role of patient experience remains underexplored. This study examines the predictive value of patient experience alongside traditional risk factors for CPSP after orthopaedic surgery. METHODS: An exploratory analysis was conducted on 294 patients from a multicentre randomised clinical trial comparing continuous perineural analgesia and single-injection nerve block in ambulatory orthopaedic surgeries. Patient experience was assessed using the Evaluation du Vecu de l'Anesthésie Générale (EVAN-G) validated questionnaire. Factors associated with CPSP at 90 days after surgery were identified through univariate and multivariate analyses, incorporating patient-reported outcomes and classical variables. RESULTS: Out of 219 patients with complete data, 63 (29%) developed CPSP at day 90. Multivariate analysis revealed a poor pain experience, as assessed by the pain dimension of EVAN-G on postoperative day 2, as an independent predictor of CPSP (odds ratio 6.45, 95% confidence interval 1.65-25.26, P<0.01). Poor pain experience was associated with an augmented risk of CPSP. CONCLUSIONS: This study underscores the role of patient-reported outcomes, specifically the pain experience dimension captured by the EVAN-G scale, in prediction of CPSP 90 days after surgery. It suggests a shift from conventional assessments of pain intensity to a comprehensive understanding of pain experience, advocating for tailored pain management approaches that could reduce chronic pain, thereby improving patient quality of life and functional recovery.

Outpatient surgery postoperative ambulation and emergency department utilization.

BACKGROUND: The ability to ambulate is an important indicator for wellness and quality of life. A major health event, such as a surgery, can derail this ability, and return to preoperative walking ability is a marker for recovery. Self-reported walking measurements by patients are subject to bias, thus wearable technology such as activity monitors have risen in popularity. We evaluated postoperative ambulation using an accelerometer in outpatient general surgery procedures with the hypothesis that those patients with less postoperative ambulation were at risk for adverse outcomes. METHODS: A retrospective review of patients undergoing outpatient abdominal surgeries from November 2016 to July 2019 at a Veteran Affairs Medical Center. Patients wore an accelerometer preoperatively and postoperatively to measure their ambulation (steps/day). Outcome measures were 30-day readmissions and Emergency Department (ED) utilization. Postoperative ambulation was defined as daily percentages of their preoperative baseline. Patients without preoperative baseline data, > 3 missing days or any missing days prior to reaching baseline were excluded. RESULTS: One-hundred-six patients underwent outpatient abdominal surgery. Twenty-two patients were excluded. Patients stratified into adult (18-64 years, 44 patients, 52%) and geriatric (≥ 65 years, 40 patients, 48%) cohorts. Geriatric patients were less likely to meet their preoperative baseline by postoperative day 7, 35% vs 61%, p = 0.016. Adult patients who failed to meet their preoperative baseline in first postoperative week had higher ED utilization; 4 (24%) vs 1 (4%), p = 0.04. Geriatric patients who failed to meet their baseline trended toward increased ED utilization; 5 (19%) vs. 1 (7%), p = 0.31. CONCLUSION: Patients aged < 65 who fail to return to their preoperative daily step count within one week of outpatient abdominal surgery are 6× more likely to be seen in the ED. Postoperative ambulation may be able to predict ED utilization and recovery after outpatient surgery.

Discharge within 24 h, transvaginal natural orifice transluminal endoscopic surgery- more suitable for ambulatory surgery in gynecology procedures: a retrospective study.

BACKGROUND: Natural orifice transluminal endoscopic surgery (NOTES) is an achievement in the field of minimally invasive surgery. However, the vantage point of vaginal natural orifice transluminal endoscopic surgery (vNOTES) in gynecologicalprocedures remains unclear. The main purpose of this study was to compare vNOTES with laparo-endoscopic single-site surgery, and to determine which procedure is more suitable for ambulatory surgery in gynecologic procedures. METHODS: This retrospective observational study was conducted at the Department of Gynecology, Chengdu Women's and Children's Central Hospital. The 207 enrolled patients had accepted vNOTES and laparo-endoscopic single-site surgery in gynecology procedures from February 2021 to March 2022. Surgically relevant information regarding patients who underwent ambulatory surgery was collected, and 64 females underwent vNOTES. RESULTS: Multiple outcomes were analyzed in 207 patients. The Wilcoxon Rank-Sum test showed that there were statistically significant differences between the vNOTES and laparo-endoscopic single-site surgery groups in terms of postoperative pain score (0 vs. 1 scores, p = 0.026), duration of anesthesia (90 vs. 101 min, p = 0.025), surgery time (65 vs. 80 min, p = 0.015), estimated blood loss (20 vs. 40 mL, p < 0.001), and intestinal exhaustion time (12.20 vs. 17.14 h, p < 0.001). Treatment with vNOTES resulted in convenience, both with respect to time savings and hemorrhage volume in surgery and with respect to the quality of the prognosis. CONCLUSION: These comprehensive data reveal the capacity of vNOTES to increase surgical efficiency. vNOTES in gynecological procedures may demonstrate sufficient feasibility and provide a new medical strategy compared with laparo-endoscopic single-site surgery for ambulatory surgery in gynecological procedures.

Driving Forces for Outpatient Total Hip and Knee Arthroplasty with Enhanced Recovery After Surgery Protocols: A Narrative Review.

PURPOSE OF REVIEW: To explore the recent developments and trends in the anesthetic and surgical practices for total hip and total knee arthroplasty and discuss the implications for further outpatient total joint arthroplasty procedures. RECENT FINDINGS: Between 2012 and 2017 there was an 18.9% increase in the annual primary total joint arthroplasty volume. Payments to physicians falling by 7.5% (14.9% when adjusted for inflations), whereas hospital reimbursements and charges increased by 0.3% and 18.6%, respectively. Total knee arthroplasty and total hip arthroplasty surgeries were removed from the Medicare Inpatient Only in January 2018 and January 2020, respectively leading to same-day TKA surgeries increases from 1.2% in January 2016 to 62.4% by December 2020 Same-day volumes for THA surgery increased from 2% in January 2016 to 54.5% by December 2020. Enhanced Recovery After Surgery (ERAS) protocols have revolutionized modern anesthesia and surgery practices. Centers for Medicare Services officially removed total joint arthroplasty from the inpatient only services list, opening a new door for improved cost savings to patients and the healthcare system alike. In the post-COVID healthcare system numerous factors have pushed increasing numbers of total joint arthroplasties into the outpatient, ambulatory surgery center setting. Improved anesthesia and surgical practices in the preoperative, intraoperative, and postoperative settings have revolutionized pain control, blood loss, and ambulatory status, rendering costly hospital stays obsolete in many cases. As the population ages and more total joint procedures are performed, the door is opening for more orthopedic procedures to exit the inpatient only setting in favor of the ambulatory setting.

The effect of a bundle intervention for ambulatory otorhinolaryngology procedures on same-day case cancellation rate and associated costs.

Cancellations within 24 h of planned elective surgical procedures reduce operating theatre efficiency, add unnecessary costs and negatively affect patient experience. We implemented a bundle intervention that aimed to reduce same-day case cancellations. This consisted of communication tools to improve patient engagement and new screening instruments (automated estimation of ASA physical status and case cancellation risk score plus four screening questions) to identify patients in advance (ideally before case booking) who needed comprehensive pre-operative risk stratification. We studied patients scheduled for ambulatory surgery with the otorhinolaryngology service at a single centre from April 2021 to December 2022. Multivariable logistic regression and interrupted time-series analyses were used to analyse the effects of this intervention on case cancellations within 24 h and costs. We analysed 1548 consecutive scheduled cases. Cancellation within 24 h occurred in 114 of 929 (12.3%) cases pre-intervention and 52 of 619 (8.4%) cases post-intervention. The cancellation rate decreased by 2.7% (95%CI 1.6-3.7%, p < 0.01) during the first month, followed by a monthly decrease of 0.2% (95%CI 0.1-0.4%, p < 0.01). This resulted in an estimated $150,200 (£118,755; €138,370) or 35.3% cost saving (p < 0.01). Median (IQR [range]) number of days between case scheduling and day of surgery decreased from 34 (21-61 [0-288]) pre-intervention to 31 (20-51 [1-250]) post-intervention (p < 0.01). Patient engagement via the electronic health record patient portal or text messaging increased from 75.9% at baseline to 90.8% (p < 0.01) post-intervention. The primary reason for case cancellation was patients' missed appointment on the day of surgery, which decreased from 7.2% pre-intervention to 4.5% post-intervention (p = 0.03). An anaesthetist-driven, clinical informatics-based bundle intervention decreases same-day case cancellation rate and associated costs in patients scheduled for ambulatory otorhinolaryngology surgery.

Improving the Rate of Same-Day Discharge in Gynecologic Oncology Patients Undergoing Minimally Invasive Surgery-An Enhanced Recovery After Surgery Quality Improvement Initiative.

OBJECTIVES: The objectives of our quality improvement (QI) initiative were (1) to increase the rate of same-day discharge (SDD) in eligible gynecologic oncology (GO) patients to 70% and (2) to evaluate the ease with which QI methods demonstrated in one study could be applied at another center. DESIGN: A pre-/postintervention design was used (50 patients/group). SETTING: SDD in patients undergoing minimally invasive GO surgery is a recent trend aligned with Enhanced Recovery After Surgery (ERAS) principles. SDD in GO is safe and feasible based on several recent studies, including a QI initiative in Edmonton, Alberta, which resulted in SDD rates >70%. PATIENTS: A baseline audit of GO patients at our center (Calgary, Alberta) found the SDD rate to be 14%. Given that Edmonton and our center are within the same province, they have similar patient populations and available resources-suggesting that interventions from the Edmonton QI initiative may be translatable. INTERVENTIONS: Four interventions were designed to address root causes for failed SDD identified after QI diagnostics: (1) SDD as the default discharge plan, including a "Day Surgery" surgical booking; (2 and 3) development and implementation of ERAS SDD preoperative and postoperative order sets; and (4) patient education SDD-specific documents. MEASUREMENTS AND MAIN RESULTS: Rate of SDD was measured together with patient demographics and surgical outcomes. Process and balancing measures were defined and tracked. SDD in GO increased from 14% (7 of 50) to 82% (41 of 50) after the implementation of the above-mentioned interventions (odds ratio [OR], 28; p <.001; 95% confidence interval [CI], 9.54-82.11). Improved SDD was achieved without negatively affecting postoperative rates of emergency department visits: 8% pre- and 4% postintervention within 7 days (OR, 0.48; p = .678; 95% CI, 0.09-2.74) and 12% pre- and 10% postintervention within 30 days (OR, 0.8148; p = 1.001; 95% CI, 0.2317-2.86). CONCLUSION: This ERAS QI initiative resulted in a substantial increase in SDD in GO, without a negative impact on balancing measures. We demonstrate that the "spread" of simple, clearly defined QI interventions across centers (where the patient population is similar) is feasible. This suggests that an ERAS SDD program for GO could be a realistic goal for other centers with similar characteristics.

Opioid free analgesia after return home in ambulatory colonic surgery patients: a single-center observational study.

BACKGROUND: Because of the adverse effects of morphine and its derivatives, non-opioid analgesia procedures are proposed after outpatient surgery. Without opioids, the ability to provide quality analgesia after the patient returns home may be questioned. We examined whether an opioid-free strategy could ensure satisfactory analgesia after ambulatory laparoscopic colectomy. METHODS: We performed a retrospective observational single-center study (of prospective collected database) including all patients eligible for scheduled outpatient colectomy. Postoperative analgesia was provided by paracetamol and nefopam. Postoperative follow-up included pain at mobilization (assessed by a numerical rating scale, NRS), hemodynamic variables, temperature, resumption of transit and biological markers of postoperative inflammation. The primary outcome was the proportion of patients with moderate to severe pain (NRS > 4) the day after surgery. RESULTS: Data from 144 patients were analyzed. The majority were men aged 59 ± 12 years with a mean BMI of 27 [25-30] kg/m2. ASA scores were 1 for 14%, 2 for 59% and 3 for 27% of patients. Forty-seven patients (33%) underwent surgery for cancer, 94 for sigmoiditis (65%) and 3 (2%) for another colonic pathology. Postoperative pain was affected by time since surgery (Q3 = 52.4,p < 0.001) and decreased significantly from day to day. The incidence of moderate to severe pain at mobilization (NRS > 4) on the first day after surgery was (0.19; 95% CI, 0.13-0.27). CONCLUSION: Non-opioid analgesia after ambulatory laparoscopic colectomy seems efficient to ensure adequate analgesia. This therapeutic strategy makes it possible to avoid the adverse effects of opioids. TRIAL REGISTRATION: The study was retrospectively registered and approved by the relevant institutional review board (CERAR) reference IRB 00010254-2018 - 188). All patients gave written informed consent for analysis of their data. The anonymous database was declared to the French Data Protection Authority (CNIL) (reference 221 2976 v0 of April 12, 2019).

Ambulatory knee arthroscopic surgery yields cost savings and improved health outcomes.

PURPOSE: This study measured the health-related quality of life (HRQoL) and costs and conducted a cost-utility analysis and budget impact analysis of ambulatory knee arthroscopic surgery compared with inpatient knee arthroscopic surgery in Thailand from a societal perspective. METHODS: Health outcomes were measured in units of quality-adjusted life year (QALY) based on the Thai version of the EQ-5D-5L Health Questionnaire, and costs were obtained from an electronic database at a tertiary care hospital (Ramathibodi Hospital). A cost-utility analysis was performed to evaluate ambulatory and inpatient surgery using the societal perspective and a 2-week time horizon. The incremental cost-effectiveness ratio was applied to examine the costs and QALYs. One-way sensitivity analysis was used to investigate the robustness of the model. Budget impact analysis was performed considering over 5 years. RESULTS: A total of 161 knee arthroscopic patients were included and divided into two groups: ambulatory surgery (58 patients) and inpatient surgery (103 patients). The total cost of the inpatient surgery was 2235 United States dollars (USD), while the ambulatory surgery cost was 2002 USD. The QALYs of inpatient surgery and ambulatory surgery were 0.79 and 0.81, respectively, resulting in the ambulatory surgery becoming a dominant strategy (cost reduction of 233 USD with an increase of 0.02 QALY) over the inpatient surgery. The ambulatory surgery led to net savings of 4.5 million USD over 5 years. Medical supply costs are one of the most influential factors affecting the change in results. CONCLUSION: Ambulatory knee arthroscopic surgery emerged as a cost-saving strategy over inpatient surgery, driven by lower treatment costs and enhanced HRQoL. Budget impact analysis indicated net savings over 5 years, supporting the feasibility of adopting ambulatory knee arthroscopic surgery. Our findings were advocated for its application across diverse hospitals and informed policymakers to improve reimbursement systems in low- to middle-income countries and Thailand. LEVEL OF EVIDENCE: Level IV.

Fully ambulatory robotic single anastomosis duodeno-ileal bypass (SADI): 40 consecutive patients in a single tertiary bariatric center.

BACKGROUND: Single Anastomosis Duodeno-Ileal bypass (SADI) is becoming a key option as a revision procedure after laparoscopic sleeve gastrectomy (LSG). However, its safety as an ambulatory procedure (length of stay < 12 h) has not been widely described. METHODS: A prospective bariatric study of 40 patients undergoing SADI robotic surgery after LSG with same day discharge (SDD), was undertaken in April 2021. Strict inclusion and exclusion criteria were applied and the enhanced recovery after bariatric surgery protocol was followed. Anesthesia and robotic procedures were standardized. Early follow-up (30 days) analyzed postoperative (PO) outcomes. RESULTS: Forty patients (37 F/3 M, mean age: 40.3yo), with a mean pre-operative BMI = 40.5 kg/m2 were operated. Median time after LSG was 54 months (21-146). Preoperative comorbidities included: hypertension (n = 3), obstructive sleep apnea (n = 2) and type 2 diabetes (n = 1). Mean total operative time was 128 min (100-180) (mean robotic time: 66 min (42-85)), including patient setup. All patients were discharged home at least 6 h after surgery. There were four minor complications (10%) and two major complications (5%) in the first 30 days postoperative (one intrabdominal abscess PO day-20 (radiological drainage and antibiotic therapy) and one peritonitis due to duodenal leak PO day-1 (treated surgically)). There were six emergency department visits (15%), readmission rate was 5% (n = 2) and reintervention rate was 2.5% (n = 1) There was no mortality and no unplanned overnight hospitalization. CONCLUSIONS: Robotic SADI can be safe for SDD, with appropriate patient selection, in a high-volume center.

Sick-leave duration after elective day case surgery in ENT: Is it affected by the type of employment?

BACKGROUND: Many ENT day-case procedures are performed on otherwise healthy individuals in employment. We hypothesised patients' type of employment may affect the amount of time taken off work following such procedures. We aimed to disprove the hypothesis that there is no difference in time taken off between employees and self-employed individuals. MATERIALS AND METHODS: We prospectively collected data on working adult patients undertaking elective day-case procedures at our department. Collected information included basic patient demographics and type of employment. A telephone call was made to collect data on actual period of time taken off work, 5-6 weeks later. RESULTS: 23% of patients were self-employed, the rest were employees. 92% of self-employed patients received no pay during their time off. This compared with 10% of employed patients receiving no pay. 77% of employed patients received full pay. Although mean time taken off work was less if the patient was self-employed (9.5 days vs 10.63), this was not found to be statistically significant. DISCUSSION AND CONCLUSION: Our study demonstrates time off work following day-case ENT procedures places a higher financial burden on self-employed patients. This should inform patient counselling prior to operations. We demonstrated no statistically significant difference in time off work post-surgery between the 2 groups. There was a possible trend towards less time off in self-employed individuals and we speculate that further research with more patients may demonstrate a statistically significant difference in time off work. Perhaps most importantly is for doctors to consider how long an individual needs off after a given procedure, after taking account of their individual patient needs, rather than defaulting to a standard 2-weeks.

Trends in payments for facility and surgeon professional fees for shoulder surgeries performed at ambulatory surgery centers.

BACKGROUND: It has previously been demonstrated that utilization of ambulatory surgery centers (ASCs) results in cost savings and improved outcomes. Despite these benefits, Medicare reimbursement for professional fees at ASCs are decreasing over time. In this study, we sought to analyze the discrepancy between facility fee and professional fee reimbursements for ASCs by Medicare for common shoulder procedures over time. We hypothesized that professional fees for shoulder procedures would decrease over the study period while facility fees kept pace with inflation. METHODS: Current Procedural Terminology codes were used to identify shoulder specific procedures approved for ASCs by Centers for Medicare and Medicaid Services. Procedures were grouped into arthroscopic and open categories. Publicly available data from Centers for Medicare and Medicaid Services was accessed via the Medicare Physician Fee Schedule Lookup Tool and used to determine professional fee payments from 2018 to 2024. Additionally, Medicare ASC Payment Rates files were accessed to determine facility fee reimbursements to ASCs from 2018 to 2024. Descriptive statistics were used to calculate means and percent change over time. Compound annual growth rates were calculated and discrepancies in inflation were corrected for using the Consumer Price Index. The Benjamini and Hochberg method was used to correct P values in the setting of multiple comparisons. RESULTS: A total of 33 common shoulder procedures were included for analysis (10 arthroscopic codes and 23 open codes). Reimbursements for facility fees have remained significantly higher than corresponding professional fees for both open and arthroscopic procedures (P < .01). On average, facility fee reimbursements for common shoulder surgeries have risen on an annual basis in a manner consistent with inflation (P = .838). However, professional fees for these procedures have experienced a nearly uniform decline over the study period both nominally and in inflation-adjusted dollars (P = .064 and P = .005, respectively). CONCLUSION: Facility fee payments for outpatient approved shoulder surgeries have matched or outpaced inflation. Over the same time period, professional fee reimbursements for surgeons are consistently decreasing, both in absolute and inflation-adjusted dollars. Reform to the physician fee schedule is necessary to ensure that Medicare patients retain access to high-quality physician care.

Effect of surgery setting for outpatient shoulder procedures on early postoperative complications in a military population.

BACKGROUND: There has been a recent push to transition procedures previously performed at hospital-based outpatient surgical departments (HOPDs) to ambulatory surgery centers (ASCs). However, limited data regarding differences in early postoperative complications and care utilization (eg, emergency department visits and unplanned admissions) may drive increased overall costs or worse outcomes. PURPOSE/HYPOTHESIS: The purpose of this study was to examine differences in early 90-day adverse outcomes and postoperative emergency department visits associated with shoulder surgeries excluding arthroplasties that were performed in HOPDs and ASCs in a closed military health care system. We hypothesized that there would be no difference in outcomes between treatment settings. METHODS: We retrospectively evaluated the records for 1748 elective shoulder surgeries from 2015 to 2020. Patients were considered as 1 of 2 cohorts depending on whether they underwent surgery in an ASC or HOPD setting. We evaluated groups for differences incomplexity, surgical time, and medical risk. Outcome measures were emergency department visits, unplanned hospital admissions, and complications within the first 90 days after surgery. RESULTS: There was no difference in 90-day postoperative emergency department visits between procedures performed at HOPDs (n = 606) and ASCs (n = 1142). There was a slight increase in rate of unplanned hospital admission within 90 days after surgery in the HOPD cohort, most commonly for pain or overnight observation. The surgical time was significantly shorter (105 vs. 119 minutes, P < .01) at the ASC, but there was no difference in case complexity between the cohorts (P = .28). DISCUSSION/CONCLUSION: Our results suggest that in appropriate patients, surgery in ASCs can be safely leveraged for its costs savings, efficiency, patient satisfaction, decreases in operative time, and potentially decreased resource utilization both during surgery and in the early postoperative period.

The Effect of Surgical Approach on the Outcomes of Same-Day Discharge Outpatient Total Hip Arthroplasty at a Single Ambulatory Surgery Center.

BACKGROUND: Primary total hip arthroplasty (THA) is increasingly being performed in the outpatient setting. However, there is little known regarding the differences in same-day discharge (SDD) rates and complications of operative approach in same-day total hip arthroplasty in the ambulatory surgery center (ASC) setting. METHODS: A retrospective chart review was performed between July 2019 and October 2021 for all patients who underwent primary THA in a single freestanding ASC. Successful SDDs, surgical approaches, lengths of surgery, estimated blood losses (EBL), complications, and readmission events were recorded for each patient. Complications were compared using Pearson Chi-Squares, while EBL and surgery lengths were compared with 1-way analysis of variances (ANOVA) (alpha = 0.5). There were 17 total complications in 326 total hip arthroplasties (5.2%), including direct admissions to the emergency department, 30-day and 90-day readmissions, wound complications, instability, infection, and revision surgery. Among all complications, there were 5 direct admissions, making the successful SDD rate 98.5%. RESULTS: Complications and direct admissions were not associated with approach. The 30-day readmission rates were associated with approach, with no readmissions in the direct anterior approach (DAA) or the antero-lateral approach (AL) cohorts and 3 (4.3%) in the posterior approach (PA) cohort. CONCLUSIONS: In the ASC setting, patients undergoing THA regardless of approach showed no difference in successful SDDs or complications aside from 30-day readmissions. Same-day THA can be safely performed in the DAA, AL, and PA to the hip.

Same Day Discharge Total Knee Arthroplasty: Hospital Demonstrates Similar Outcomes to Ambulatory Surgery Center in a More Complex Patient Population.

BACKGROUND: The purpose of this study was to compare outcomes between patients undergoing same-day discharge (SDD) total knee arthroplasty (TKA) at an ambulatory surgery center (ASC) versus a tertiary care university hospital setting. METHODS: A single tertiary academic center's institutional database was reviewed for patients who underwent primary TKA and were discharged the same day from August 2021 to January 2024. Patients who did not have at least 1 year of follow-up were excluded. Patient demographics, comorbidities, patient-reported outcome measures, emergency department visits, admissions, reoperations, and revisions were collected. Patients were stratified by the location of their surgery: ASC versus hospital. Specific criteria had to be met prior to surgery at the ASC, and the final decision regarding the location of surgery was made via shared decision-making between the patient and their surgeon. Patients who did not meet ASC criteria underwent TKA at the main hospital. Univariable analyses were used to compare groups, and multivariable logistic regression was used to determine if surgical location was a significant factor. Of the 449 TKAs meeting inclusion criteria, 63.3% (284) were performed at the ASC and 36.7% (165) at the university hospital at a mean follow-up of 1.51 years (range, 1.00 to 2.40). Of those 165 whose surgery was done at the hospital, 93.9% met at least one ASC exclusion criteria. RESULTS: Patients whose TKA was done at the hospital had significantly higher weight (P = 0.003), body mass index (P < 0.001), Elixhauser comorbidity index (P < 0.001), proportion of patients who had an American Society of Anesthesiologists classification of 3 (P = 0.023), and proportion of patients who required general anesthesia (P < 0.001). Additionally, patients whose TKA was done at the hospital had higher preoperative patient-reported outcome measurement information system (PROMIS) pain interference (PI) (62.0 [59.0, 66.0] versus 63.0 [61.8, 67.0]; P = 0.006), and lower physical function (PF) (39.0 [36.0, 43.0] versus 38.0 [34.0, 41.0]; P = 0.001). At 1 year, however, patients in both groups had similar PROMIS PI (53.0 [49.0, 59.0] versus 54.0 [44.0, 59.0]; P = 0.785) and PROMIS PF (47.0 [42.0, 51.0] versus 47.0 [41.0, 50.0]; P = 0.422) scores as well as similar rates of achieving minimum clinically important difference for PROMIS PI (64.4 versus 71.4%; P = 0.336) and PROMIS PF (60.5 versus 71.4%; P = 0.124). They also had a similar number of emergency department visits and admissions at 30 and 90 days, as well as similar reoperation-free (92.0 versus 93.3%; P = 0.79) and revision-free (95.5 versus 99.4%; P = 0.59) survival at 2 years CONCLUSIONS: Although ASCs have strict patient criteria for SDD TKA, complex patients at a tertiary university hospital can be sent home the same day with equivalent outcomes. Therefore, unhealthier patients can safely achieve SDD without compromising outcomes if done in the appropriate setting.

Advanced Concepts in Outpatient Joint Arthroplasty.

As the adoption and utilization of outpatient total joint arthroplasty continues to grow, key developments have enabled surgeons to safely and effectively perform these surgeries while increasing patient satisfaction and operating room efficiency. Here, the authors will discuss the evidence-based principles that have guided this paradigm shift in joint arthroplasty surgery, as well as practical methods for selecting appropriate candidates and optimizing perioperative care. There will be 5 core efficiency principles reviewed that can be used to improve organizational management, streamline workflow, and overcome barriers in the ambulatory surgery center. Finally, future directions in outpatient surgery at the ASC, including the merits of implementing robot assistance and computer navigation, as well as expanding indications for revision surgeries, will be debated.