The transition to outpatient shoulder arthroplasty: a systematic review.

BACKGROUND AND HYPOTHESIS: Transitioning shoulder arthroplasty (SA) from an inpatient to outpatient procedure is associated with increased patient satisfaction and potentially decreased costs; however, concerns exist about complications following same-day discharge. We hypothesized that outpatient SA would be associated with low rates of failed discharges, readmissions, and complications, rendering it a safe and effective option for SA. METHODS: A systematic review of the outpatient SA literature identified 16 of 447 studies with level III and IV evidence that met the inclusion criteria with at least 90 days of follow-up. Data on patient demographic characteristics, preoperative and postoperative protocols, surgery characteristics, failed discharges, complications, and readmissions were collected and pooled for analysis. RESULTS: A total of 990 patients were included in our analysis. Many studies identified specific institutional protocols for determining eligibility for outpatient SA, including preoperative clearance from an anesthesiologist; identification of a perioperative caretaker; and exclusion of patients based on cardiac, pulmonary, or hematologic risk factors. Failed same-day discharge occurred in only 0.9% of patients (7 of 788), and 2.1% of patients (9 of 418) and 0.79% of patients (2 of 252) presented to an emergency department or urgent care facility for a perioperative concern. The readmission rate for periprosthetic fracture, arthrofibrosis, infection, subscapularis rupture, and anterior subluxation was 1.3% (7 of 529 patients). Complications occurred in 7.0% of patients (70 of 990), with 5.4% of patients (53 of 990) experiencing a surgical complication and 1.7% (17 of 990) having a medical complication. There were 28 total reoperations (2.9%, 28 of 955 patients). DISCUSSION AND CONCLUSION: Outpatient SA is associated with low rates of failed discharges, readmissions, and complications. Additionally, the medical and surgical complications that occur after outpatient SA are unlikely to be prevented by the short inpatient stay characteristic of traditional SA. With careful screening measures to identify appropriate candidates for same-day discharge, outpatient SA represents a safe approach to prevent unnecessary hospitalizations and to decrease costs associated with SA.

Variation in state and federal reimbursement in the United States in the treatment of upper extremity fractures.

BACKGROUND: Medicare and Medicaid are 2 of the largest government-run health care programs in the United States. Although Medicare reimbursement is determined at the federal level by the Centers for Medicare & Medicaid Services, Medicaid reimbursement rates are set by each individual state. The purpose of this study is to compare Medicaid reimbursement rates with regional Medicare reimbursement rates for 12 orthopedic procedures performed to treat common fractures of the upper extremity. METHODS: Twelve orthopedic procedures were selected and their Medicare reimbursement rates were collected from the 2020 Medicare Physician Fee Schedule. Medicaid reimbursement rates were obtained from each state's physician fee schedule. Reimbursement rates were then compared by assessing the ratio of Medicaid to Medicare, the dollar difference in Medicaid to Medicare reimbursement, and the difference per relative value unit. The range of variation in Medicaid reimbursement and Medicare wage index-adjusted Medicaid reimbursement was calculated. Comparisons in reimbursement were calculated using coefficient of variation and Student t tests to evaluate the differences between the mean Medicaid and Medicare reimbursements. Two-sample coefficient of variation testing was used to determine whether dispersion in Medicare and Medicaid reimbursement rates differed significantly. RESULTS: There was significant difference in reimbursement rates between Medicare and Medicaid for all 12 procedures, with Medicare reimbursing on average 46.5% more than Medicaid. In 40 states, Medicaid reimbursed less than Medicare for all 12 procedures. Regarding the dollar difference per relative value unit, Medicaid reimbursed on average $18.03 less per relative value unit than Medicare. The coefficient of variation for Medicaid reimbursement rates ranged from 0.26-0.33. This is in stark contrast with the significantly lower variability observed in Medicare reimbursement, which ranged from 0.06-0.07. CONCLUSION: Our findings highlight the variation in reimbursement that exists among state Medicaid programs for 12 orthopedic procedures commonly used to treat fractures of the upper extremity. Furthermore, average Medicaid reimbursement rates were significantly lower than Medicare rates for all 12 procedures. Such discrepancies in reimbursement may act as a barrier, impeding many Medicaid patients from accessing timely orthopedic care.

Nerve Reconstruction Using Processed Nerve Allograft in the U.S. Military.

BACKGROUND: Processed nerve allograft (PNA) is an alternative to autograft for the reconstruction of peripheral nerves. We hypothesize that peripheral nerve repair with PNA in a military population will have a low rate of meaningful recovery (M ≥ 3) because of the frequency of blasting mechanisms and large zones of injury. METHODS: A retrospective review of the military Registry of Avance Nerve Graft Evaluating Utilization and Outcomes for the Reconstruction of Peripheral Nerve Discontinuities database was conducted at the Walter Reed Peripheral Nerve Consortium. All adult active duty military patients who underwent any peripheral nerve repair with PNA for complete nerve injuries augmented with PNA visit were included. Motor strength and sensory function were reported as a consensus from the multidisciplinary Peripheral Nerve Consortium. Motor and sensory testing was conducted in accordance with the British Medical Research Council. RESULTS: A total of 23 service members with 25 nerve injuries (3 sensory and 22 mixed motor/sensory) underwent reconstruction with PNA. The average age was 30 years and the majority were male (96%). The most common injury was to the sciatic nerve (28%) from a complex mechanism (gunshot, blast, compression, and avulsion). The average defect was 77 mm. Twenty-four percent of patients achieved a meaningful motor recovery. Longer follow-up was correlated with improved postoperative motor function (r = 0.49 and P = .03). CONCLUSIONS: The military population had complex injuries with large nerve gaps. Despite the low rate of meaningful recovery (27.3%), large gaps in motor and mixed motor/sensory nerves are difficult to treat, and further research is needed to determine if autograft would achieve superior results. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level III.