Outpatient Surgery and Unplanned Overnight Admission in Bilateral Inguinal Hernia Repair: A Population-based Study.

PURPOSE: The use of outpatient surgery in inguinal hernia is heterogeneous despite clinical recommendations. This study aimed to analyze the utilization trend of outpatient surgery for bilateral inguinal hernia repair (BHIR) in Spain and identify the factors associated with outpatient surgery choice and unplanned overnight admission. METHODS: A retrospective observational study of patients undergoing BIHR from 2016 to 2021 was conducted. The clinical-administrative database of the Spanish Ministry of Health RAE-CMBD was used. Patient characteristics undergoing outpatient and inpatient surgery were compared. A multivariable logistic regression analysis was performed to identify factors associated with outpatient surgery choice and unplanned overnight admission. RESULTS: A total of 30,940 RHIBs were performed; 63% were inpatient surgery, and 37% were outpatient surgery. The rate of outpatient surgery increased from 30% in 2016 to 41% in 2021 (p < 0.001). Higher rates of outpatient surgery were observed across hospitals with a higher number of cases per year (p < 0.001). Factors associated with outpatient surgery choice were: age under 65 years (OR: 2.01, 95% CI: 1.92-2.11), hospital volume (OR: 1.59, 95% CI: 1.47-1.72), primary hernia (OR: 1.89, 95% CI: 1.71-2.08), and laparoscopic surgery (OR: 1.47, 95% CI: 1.39-1.56). Comorbidities were negatively associated with outpatient surgery. Open surgery was associated (OR: 1.26, 95% CI: 1.09-1.47) with unplanned overnight admission. CONCLUSIONS: Outpatient surgery for BHIR has increased in recent years but is still low. Older age and comorbidities were associated with lower rates of outpatient surgery. However, the laparoscopic repair was associated with increased outpatient surgery and lower unplanned overnight admission.

Outpatient and Ambulatory Extended Recovery Robotic Hepatectomy: Multinational Study of 307 Cases.

BACKGROUND: For open minor hepatectomy, morbidity and recovery are dominated by the incision. The robotic approach may transform this "incision dominant procedure" into a safe outpatient procedure. STUDY DESIGN: We audited outpatient (less than 2 midnights) robotic hepatectomy at 6 hepatobiliary centers in 2 nations to test the hypothesis that the robotic approach can be a safe and effective short-stay procedure. Establishing early recovery after surgery programs were active at all sites, and home digital monitoring was available at 1 of the institutions. RESULTS: A total of 307 outpatient (26 same-day and 281 next-day discharge) robotic hepatectomies were identified (2013 to 2023). Most were minor hepatectomies (194 single segments, 90 bi-segmentectomies, 14 three segments, and 8 four segments). Thirty-nine (13%) were for benign histology, whereas 268 were for cancer (33 hepatocellular carcinoma, 27 biliary, and 208 metastatic disease). Patient characteristics were a median age of 60 years (18 to 93 years), 55% male, and a median BMI of 26 kg/m 2 (14 to 63 kg/m 2 ). Thirty (10%) patients had cirrhosis. One hundred eighty-seven (61%) had previous abdominal operation. Median operative time was 163 minutes (30 to 433 minutes), with a median blood loss of 50 mL (10 to 900 mL). There were no deaths and 6 complications (2%): 2 wound infections, 1 failure to thrive, and 3 perihepatic abscesses. Readmission was required in 5 (1.6%) patients. Of the 268 malignancy cases, 25 (9%) were R1 resections. Of the 128 with superior segment resections (segments 7, 8, 4A, 2, and 1), there were 12 positive margins (9%) and 2 readmissions for abscess. CONCLUSIONS: Outpatient robotic hepatectomy in well-selected cases is safe (0 mortality, 2% complication, and 1.6% readmission), including resection in the superior or posterior portions of the liver that is challenging with nonarticulating laparoscopic instruments.

Vasectomy: An increasingly common procedure in France.

OBJECTIVES: To analyze the evolutionary trends concerning vasectomy over the last 8 years in order to better understand the situation and identify measures to be implemented to develop this activity. METHODS: The number of vasectomy procedures performed between 2015 and 2022 was extracted from the Open CCAM file compiled from the national database of the Programme de médicalisation du système d'informations français (PMSI). RESULTS: Over the period 2015-2022, the number of vasectomy procedures increased from 3743 in 2015 to 29,890 in 2022. This increase was observed in all French metropolitan and overseas regions. The number of minimally invasive vasectomies (notably without scalpel) rose sharply, from 313 to 7760. Almost all vasectomies were performed during outpatient hospitalization (0 nights), with fewer than 300 acts reported/year in outpatient care. CONCLUSION: In France, vasectomy is becoming an increasingly frequent contraceptive method. This analysis is in line with recent surveys carried out in France, and tends to prove that more and more couples of childbearing age are in favour of sharing the contraceptive burden.

Predictors of extended length of stay following outpatient reduction mammaplasty.

PURPOSE: Reduction mammaplasty has transitioned into a largely outpatient procedure in the United States. Following planned outpatient procedures, patients may still be admitted for additional inpatient care, incurring clinical and economic burden. Prior literature has not explored the preoperative and perioperative determinants of extended lengths of stay (LOS) after breast reduction surgery. METHODS: Patients who underwent scheduled outpatient reduction mammaplasty were identified via current procedural terminology code from the 2013 to 2021 National Surgical Quality Improvement Program databases. The primary outcome was extended LOS, defined as an LOS greater than 1 day. The most significant predictor variables were identified through bivariate association, and a binary logistic regression model was used to characterize predictive associations (p < 0.05). RESULTS: In this study, 33,924 patients were included in the final cohort of planned outpatient reduction mammaplasty cases. Among them 325 (1.0%) patients had extended LOS. Concurrent liposuction, body contouring, and increased operative time were the most significant predictors of extended LOS (p < 0.001), followed by older age, higher body mass index, bleeding disorder, history of diabetes, higher American Society of Anesthesiologists class, and White race (p < 0.05). When adjusted for other confounding variables, extended LOS was also a significant predictor of increased risk of postoperative complications after discharge (OR: 1.85, 95% confidence intervals: 1.27-2.69, p = 0.0012). CONCLUSION: Extended LOS after planned outpatient reduction mammaplasty is associated with specific comorbidities, and is a significant predictor of postoperative complications following hospital discharge. DATA AVAILABILITY STATEMENT: The data that support the findings of this study are publicly available.

Time from surgery end to discharge following total knee arthroplasty: implications for same day discharge.

BACKGROUND: Understanding the average time from surgery to discharge is important to successfully and strategically schedule cases planned for same day discharge (SDD) for total knee arthroplasty (TKA). The purpose of this study was to (1) evaluate the average time to discharge following unilateral TKA performed in a community hospital and (2) describe patient characteristics and peri-operative factors that may impact SDD. METHODS: This retrospective review included 75 patients having achieved SDD following unilateral TKA between March 2017 and September 2021 at a high-volume multi-specialty community hospital. Time to discharge was calculated from end of surgery, defined as completion of dressing application, to physical discharge from the hospital. Time surgery completed and association with time of discharge was also examined. Pearson's correlations were performed to evaluate the relationship between total time to discharge and patient demographics. RESULTS: The average age for all patients was 66.6 ± 10.9 years (Range: 38 to 86) and average BMI of 29.9 ± 5.6 kg/m2 (Range: 20.4 to 46.3). The average time to discharge was 5.8 ± 1.8 h (range: 2.2 to 10.5 h). Time to discharge was significantly longer for patients finishing surgery prior to noon (6.0 ± 1.8 h), than after noon (4.8 ± 1.4 h, p = 0.046). Total time to discharge was not correlated with age (r = 0.018, p = 0.881) or BMI (r=-0.158, p = 0.178), but was negatively correlated with surgical start time (r=-0.196, p = 0.094). CONCLUSION: An average of six hours was required to achieve SDD following unilateral TKA performed in a community hospital. The time required for SDD was not found to be related to intrinsic patient factors but more likely due to extrinsic factors associated with time of scheduled surgery. To improve success of SDD, focus should be placed on the development of efficient discharge pathways rather than unchangeable intrinsic patient characteristics.

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.

Global International Society of University Colon and Rectal Surgeons in collaboration with European Society of Coloproctology audit on office-based and surgical treatment of haemorrhoidal disease: Study protocol.

AIM: Haemorrhoidal disease (HD) is one of the most common anal disorders in the adult population. Despite that, treatment options differ among different countries and specialists, even for the same grade of HD. The aim of this study is to evaluate the differences in patient demographics, surgeon preference for the treatment option, outcomes as well as patient satisfaction rate for the procedure using an office-based or surgical approach for the treatment of HD among International Society of University Colon and Rectal Surgeons (ISUCRS) and European Society of Coloproctology (ECSP) fellows. METHOD: A panel of the ISUCRS and ECSP members will answer questions that are included in a questionnaire about the treatment of HD. The questionnaire will be distributed electronically to ISUCRS and ECSP fellows included in our database and will remain open from 1 April 2024 to 31 May 2024. CONCLUSION: This multicentre, global prospective audit will be delivered by consultant colorectal and general surgeons as well as trainees. The data obtained will lead to a better understanding of the incidence of HD, treatment and diagnostic possibilities. This snapshot audit will be hypothesis generating and inform areas the need future prospective study.

Transfers and anesthesia-related postoperative outcomes after 3361 same-day cancer surgeries at a freestanding surgery center: An observational retrospective study.

BACKGROUND AND OBJECTIVES: Expanding outpatient surgery to the increasing number of procedures and patient populations warrants continuous evaluation of postoperative outcomes to ensure the best care and safety. We describe adverse postoperative outcomes and transfer rates related to anesthesia in a large sample of patients who underwent same-day cancer surgery at a freestanding ambulatory surgery center. METHODS: Between January 2017 and June 2021, 3361 cancer surgeries, including breast and plastic, head and neck, gynecology, and urology, were performed. The surgeries were indicated for diagnosis, staging, and/or treatment. We report the incidence of transfers and adverse postoperative outcomes related to anesthesia. RESULTS: Breast and plastic surgeries were the most common (1771, 53%), followed by urology (1052, 31%), gynecology (410, 12%), and head and neck surgeries (128, 4%). Based on patients' first procedure, comorbidity levels were highest for urology (75% American Society of Anesthesiologists physical status score 3, 1.7% score 4) and lowest for breast surgeries (31% score 3, 0.2% score 4). Most gynecology surgeries used general anesthesia (97.6%), whereas breast surgeries used the least (38%). A total of seven patients (0.2%; 95% CI: 0.08%-0.4%) were immediately transferred to an outside hospital; four due to anesthesia-related reasons. Only 7 (0.2%) patients needed additional postoperative care related to anesthesia-related adverse events, specifically cardiac events (4), difficult intubations (2), desaturation (1), and agitation, nausea, and headache (1). CONCLUSIONS: The incidence of anesthesia-related adverse postoperative outcomes is low in cancer patients undergoing outpatient surgeries at our freestanding ambulatory surgery center. This suggests that carefully selected cancer patients, including patients with metastatic cancer, can undergo anesthesia for same-day surgery, making cancer care accessible locally and reducing stress associated with travel for treatment. More research investigating complication rates related to surgery and to cancer disease trajectory are needed to establish a complete evaluation of safety for outpatient cancer surgery.

Ten Year Experience With Same Day Discharge Outpatient Total Hip Arthroplasty: Patient Demographics Changed, but Safe Outcomes Were Maintained.

BACKGROUND: This study aimed to characterize changes in patient demographics and outcomes for same-day discharge total hip arthroplasty (THA) over a 10-year period at a single orthopaedic specialty hospital. METHODS: A consecutive series of 1,654 patients between 2013 and 2022 who underwent unilateral THA and were discharged on the same calendar day were retrospectively reviewed. Patient demographics, including age, sex, body mass index (BMI), age-adjusted Charlson Comorbidity Index, and American Society of Anesthesiologists (ASA), were collected. Readmissions, complications, and unplanned visits were recorded for 90 days postoperatively. In order to compare the demographics of patients over time, patients were divided into 3 groups: Time Group A (2013 to 2016), Time Group B (2017 to 2019), and Time Group C (2020 to 2022). RESULTS: The mean age, BMI, ASA score, and CCI increased significantly across each time group. Age increased from 57 years (range, 23 to 77) to 60 years (range, 20 to 87). The BMI increased from 28.1 (range, 18 to 41) to 29.4 (range, 18 to 47). The percentage of patients aged > 70 years almost doubled over time, as did the percentage of patients who had a BMI > 35. Overall complications increased from 3.44 to 6.82%, reflective of the changing health status of patients. Readmissions increased from 0.57 to 1.70% over time. Despite this, there were no readmissions for any patient within the first 24 hours of surgery. CONCLUSIONS: Our study has 3 important findings. We identified a worsening patient demographic over time with an increasing percentage of patients of advanced age and higher BMI, ASA, and age-adjusted Charlson Comorbidity Index. Also, there was also an increase in readmissions, complications, and unplanned visits. In addition, despite this worsening patient demographic, there were no readmissions within 24 hours and a low rate of readmissions or unplanned visits within the first 48 hours across all time periods, suggesting that same-day discharge-THA continues to be safe in properly selected patients.

Impact of Replacing Fentanyl With Hydromorphone as the First-Line Postoperative Opioid Among Patients Undergoing Outpatient Cancer Surgery.

PURPOSE: In response to a nationwide fentanyl shortage, our institution assessed whether changing our first-line postoperative intravenous opioid from fentanyl to hydromorphone impacted patient outcomes. The primary research aim was to evaluate the association between first-line opioid and rapidity of recovery. DESIGN: The study team retrospectively obtained data on all consecutive patients extracted from the electronic medical record. The rapidity of recovery was defined as the time from entry into the postanesthesia care unit to the transition to Phase 2 for ambulatory extended recovery patients and as the length of total postanesthesia care unit stay for outpatients. METHODS: Following intent-to-treat-principles, we tested the association between study period and rapidity of recovery (a priori clinically meaningful difference: 20 minutes) using multivariable linear regression, adjusting for anesthesia type (general vs monitored anesthesia care), American Society of Anesthesiologst physical status (ASA) score (1-2 vs 3-4), age, service, robotic procedure, and surgery start time. FINDINGS: Ambulatory extended recovery patients treated in the hydromorphone period had, on average, a 0.25 minute (95% confidence interval [CI] -6.5, 7.0), nonstatistically significant (P > .9) longer time to transition. For outpatient procedures, those who received hydromorphone had, on average, 8.5-minute longer stays (95% CI 3.7-13, P < .001). Although we saw statistical evidence of an increased risk of resurgery associated with receiving hydromorphone (0.5%; 95% CI -0.1%, 1.0%; P = .039 on univariate analysis), the size of the estimate is clinically and biologically implausible and is most likely a chance finding related either to multiple testing or confounding. CONCLUSIONS: The multidisciplinary team concluded that the increase in postoperative length of stay associated with hydromorphone was not clinically significant and the decrease waste of prefilled syringes outweighed the small potential increased risk of resurgery compared to the shorter-acting fentanyl. We will therefore use hydromorphone moving forward.

Trends in the Adoption of Outpatient Joint Arthroplasties and Patient Risk: A Retrospective Analysis of 2019 to 2021 Medicare Claims Data.

INTRODUCTION: Total joint arthroplasties (TJAs) have recently been shifting toward outpatient arthroplasty. This study aims to explore recent trends in outpatient total joint arthroplasty (TJA) procedures and examine whether patients with a higher comorbidity burden are undergoing outpatient arthroplasty. METHODS: Medicare fee-for-service claims were screened for patients who underwent total hip, knee, or shoulder arthroplasty procedures between January 2019 and December 2022. The procedure was considered to be outpatient if the patient was discharged on the same date of the procedure. The Hierarchical Condition Category Score (HCC) and the Charlson Comorbidity Index (CCI) scores were used to assess patient comorbidity burden. Patient adverse outcomes included all-cause hospital readmission, mortality, and postoperative complications. Logistic regression analyses were used to evaluate if higher HCC/CCI scores were associated with adverse patient outcomes. RESULTS: A total of 69,520, 116,411, and 41,922 respective total knee, hip, and shoulder arthroplasties were identified, respectively. Despite earlier removal from the inpatient-only list, outpatient knee and hip surgical volume did not markedly increase until the pandemic started. By 2022Q4, 16%, 23%, and 36% of hip, knee, and shoulder arthroplasties were discharged on the same day of surgery, respectively. Both HCC and CCI risk scores in outpatients increased over time ( P < 0.001). DISCUSSION: TJA procedures are shifting toward outpatient surgery over time, largely driven by the COVID-19 pandemic. TJA outpatients' HCC and CCI risk scores increased over this same period, and additional research to determine the effects of this should be pursued. LEVEL OF EVIDENCE: Level III, therapeutic retrospective cohort study.

Site of Service Disparities Exist for Total Joint Arthroplasty.

BACKGROUND: The rate of outpatient total joint arthroplasty procedures, including those performed at ambulatory surgical centers (ASCs) and hospital outpatient departments, is increasing. The purpose of this study was to analyze if type of insurance is associated with site of service (in-patient vs outpatient) for total joint arthroplasty and adverse outcomes. MATERIALS AND METHODS: We identified patients undergoing unicompartmental knee arthroplasty (UKA), total knee arthroplasty (TKA), or total hip arthroplasty (THA) using Current Procedural Terminology codes in a national administrative claims database. Eligible patients were stratified by type of insurance (Medicaid, Medicare, private). The primary outcome was site of service. Secondary outcomes included general complications, procedural complications, and revision procedures. We evaluated the associations using adjusted multivariable logistic regression models. RESULTS: We identified 951,568 patients for analysis; 46,703 (4.9%) patients underwent UKA, 607,221 (63.8%) underwent TKA, and 297,644 (31.3%) underwent THA. Overall, 9.6% of procedures were outpatient. Patients with Medicaid were less likely than privately insured patients to receive outpatient UKA or THA (UKA: odds ratio [OR], 0.729 [95% CI, 0.640-0.829]; THA: OR, 0.625 [95% CI, 0.557-0.702]) but more likely than patients with Medicare to receive outpatient TKA or THA (TKA: OR, 1.391 [95% CI, 1.315-1.472]; THA: OR, 1.327 [95% CI, 1.166-1.506]). Patients with Medicaid were more likely to experience complications and revision procedures. CONCLUSION: Differences in site of service and complication rates following hip and knee arthroplasty exist based on type of insurance, suggesting a disparity in care. Further exploration of drivers of this disparity is warranted and can inform interventions (eg, progressive value-based payments) to support equity in orthopedic services. [Orthopedics. 2024;47(3):179-184.].

Proyecto DUCMA 2.0. Puesta al día sobre la situación actual de las unidades de Cirugía Mayor Ambulatoria en España / DUCMA 2.0 project: Update on the current situation of the outpatient surgery units in Spain

Introducción: La cirugía mayor ambulatoria (CMA) es un sistema de gestión seguro y eficiente para resolver los problemas quirúrgicos, pero su implantación y desarrollo ha sido variable. El objetivo de este estudio es describir las características, la estructura y el funcionamiento de las unidades de Cirugía Mayor Ambulatoria (UCMA) en España. Métodos: Estudio observacional, transversal, multicéntrico basado en una encuesta electrónica, con recogida de datos entre abril y septiembre de 2022. Resultados: En total, 90 UCMA completaron la encuesta. La media del índice de ambulatorización (IA) global es de 63%. Más de la mitad de las UCMA (52%) son de tipo integrado. La mitad las unidades imparte formación para médicos (51%) y personal de enfermería (55%). Los indicadores de calidad más utilizados son la tasa de suspensiones (87%) y de ingresos no previstos (80%). Conclusiones: Se necesita mayor coordinación entre administraciones para obtener datos fiables. Asimismo, se deben implementar sistemas de gestión de calidad en las unidades y desarrollar herramientas para la formación adecuada de los profesionales implicados.(AU)

Introduction: Ambulatory surgery is a safe and efficient management system to solve surgical problems, but its implementation and development has been variable. The aim of this study is to describe the characteristics, structure and functioning of ambulatory surgery units (ASU) in Spain. Methods: Multicenter, cross-sectional, observational study based on an electronic survey, with data collection between April and September 2022. Results: In total, 90 ASUs completed the survey. The mean overall ambulatory index is 63%. More than half of the ASUs (52%) are integrated units. Around half of the units provide training for physicians (51%) and for nurses (55%). The most frequently used quality indicators are suspension rate (87%) and the rate of unplanned admissions (80%). Conclusions: Greater coordination between administrations is needed to obtain reliable data. It is also necessary to implement quality management systems in the different units, as well as to develop tools for the adequate training of the professionals involved.(AU)

Postoperative racial disparities following spine surgery are less pronounced in the outpatient setting.

BACKGROUND CONTEXT: Racial disparities in spine surgery have been thoroughly documented in the inpatient (IP) setting. However, despite an increasing proportion of procedures being performed as same-day surgeries, whether similar differences have developed in the outpatient (OP) setting remains to be elucidated. PURPOSE: This study aimed to investigate racial differences in postoperative outcomes between Black and White patients following OP and IP lumbar and cervical spine surgery. STUDY DESIGN/SETTING: Retrospective cohort study. PATIENT SAMPLE: Patients who underwent IP or OP microdiscectomy, laminectomy, anterior cervical discectomy and fusion (ACDF), or cervical disc replacement (CDR) between 2017 and 2021. OUTCOME MEASURES: Thirty-day rates of serious and minor adverse events, readmission, reoperation, nonhome discharge, and mortality. METHODS: A retrospective review of patients who underwent IP or OP microdiscectomy, laminectomy, anterior cervical discectomy and fusion (ACDF), or cervical disc replacement (CDR) between 2017 and 2021 was conducted using the National Surgical Quality Improvement Program (NSQIP) database. Disparities between Black and White patients in (1) adverse event rates, (2) readmission rates, (3) reoperation rates, (4) nonhome discharge rates, (5) mortality rates, (6) operative times, and (7) hospital LOS between Black and White patients were measured and compared between IP and OP surgical settings. Multivariable logistic regression analyses were used to adjust for potential effects of baseline demographic and clinical differences. RESULTS: Of 81,696 total surgeries, 49,351 (60.4%) were performed as IP and 32,345 (39.6%) were performed as OP procedures. White patients accounted for a greater proportion of IP (88.2% vs 11.8%) and OP (92.7% vs 7.3%) procedures than Black patients. Following IP surgery, Black patients experienced greater odds of serious (OR 1.214, 95% CI 1.077-1.370, p=.002) and minor adverse events (OR 1.377, 95% CI 1.113-1.705, p=.003), readmission (OR 1.284, 95% CI 1.130-1.459, p<.001), reoperation (OR 1.194, 95% CI 1.013-1.407, p=.035), and nonhome discharge (OR 2.304, 95% CI 2.101-2.528, p<.001) after baseline adjustment. Disparities were less prominent in the OP setting, as Black patients exhibited greater odds of readmission (OR 1.341, 95% CI 1.036-1.735, p=.026) but were no more likely than White patients to experience adverse events, reoperation, individual complications, nonhome discharge, or death (p>.050 for all). CONCLUSIONS: Racial inequality in postoperative complications following spine surgery is evident, however disparities in complication rates are relatively less following OP compared to IP procedures. Further work may be beneficial in elucidating the causes of these differences to better understand and mitigate overall racial disparities within the inpatient setting. These decreased differences may also provide promising indication that progress towards reducing inequality is possible as spine care transitions to the OP setting.

Analysis of endonasal sinus surgery in a private outpatient setting in a tropical environment: A STROBE analysis.

OBJECTIVES: To evaluate results and failure factors in endonasal surgery in a private outpatient setting in a tropical environment. MATERIAL AND METHOD: A single-center observational study included 337 patients consecutively undergoing endonasal surgery in a private hospital on Réunion Island, a French overseas administrative Département in the Indian Ocean between 2019 and 2021. The main objective was to assess the success rate of the outpatient pathway. Secondary objectives comprised analysis of complications and identification and management of factors for failure of outpatient management. The study was conducted according to the STROBE editorial guideline. RESULTS: The 337 surgeries notably comprised 112 septoplasties (37.5%), 104 meatotomies (30.3%), 15 unilateral total ethmoidectomies (4.6%), 48 bilateral total ethmoidectomies with sphenoidotomy (14.3%), and 18 Draf procedures (5.5%). Seventy-five percent of patients (252/337) were operated on as outpatients, with a success rate of 90% (227/252 patients). The rate of severe intraoperative complications was 1.5% (5/337). On multivariate analysis, 3 variables were identified as influencing risk of failure of the outpatient pathway: emergency analgesia in the operating room [odds ratio (OR): 91.61; 95% confidence interval (CI): 22.8-540.3], operating time (OR: 1.05; 95% CI: 1.01-1.09), and recovery room time (OR: 1.02; 95% CI: 1.01-1.03). CONCLUSION: Our study in a tropical environment found eligibility and success rates for outpatient endonasal surgery similar to those in metropolitan France. This makes surgical and anesthesiological training a key factor in the success of outpatient care, while the location of the care structure and the climate seem to have little impact.

Outpatient Total Hip Arthroplasty Volume up Nearly 8-Fold After Regulatory Changes With Expanding Demographics and Unchanging Outcomes: A 10-Year Analysis.

BACKGROUND: With the removal of total hip arthroplasty (THA) from the inpatient-only (IPO) lists, the orthopedic landscape across the United States has changed rapidly. Thus, this study aimed to: 1) characterize the change in THA volume for outpatient and inpatient surgeries; 2) elucidate demographical differences before and after removal from the IPO list; and 3) analyze 30-day complications, readmissions, and reoperations. METHODS: The National Surgical Quality Improvement Program database was queried for primary THAs between January 2010 and December 2021. The primary outcome was the annual volume of outpatient and inpatient THAs. Secondary outcomes involved 30-day complications, readmissions, and reoperations. The variables between cohorts were analyzed using goodness-of-fit Chi-square tests with summary statistics. RESULTS: Of the 332,423 THAs between 2010 and 2021, 88% were inpatient THAs (n = 292,974) and 12% were outpatient THAs (n = 39,449). From 2019 to 2021, the volume of inpatient THA decreased by 55% (42,779 to 19,075), while outpatient THA increased by 751% (2,518 to 21,424). Patients who had a THA after 2019 were older (P < .001), more commonly women (P < .001), white (P < .001), and more likely American Society of Anesthesiologists Class III (P < .001). The outpatient cohort had fewer 30-day complications, readmissions, and reoperations. The length of stay for both cohorts decreased until 2019, before increasing in 2020 and 2021 for inpatient THAs, while home discharge and operative time increased for both. CONCLUSIONS: The volume of outpatient THA increased almost eightfold after its removal from the IPO lists in 2020. Despite expanding eligibility with older patients and more comorbidities, 30-day complications, readmissions, and reoperations remain low. These findings support the safe transition to outpatient THA with appropriate patient selection and optimization.

Same day discharge colon surgery: is it financially worth it?

AIM: Same day discharge (SDD) for colorectal surgery shows increasing promise in the era of enhanced recovery after surgery protocols and minimally invasive surgery. It has become increasingly relevant due to the constraints posed by the COVID-19 pandemic. The aim of this study was to compare SDD and postoperative day 1 (POD1) discharge to understand the clinical outcomes and financial impact on factors such as cost, charge, revenue, contribution margin and readmission. METHOD: A retrospective review of colectomies was performed at a single institution over a 2-year period (n = 143). Two populations were identified: SDD (n = 51) and POD1 (n = 92). Patients were selected by International Statistical Classification of Diseases and Related Health Problems-10 (ICD-10) and Diagnosis Related Grouper (DRG) codes. RESULTS: There was a statistically significant difference favouring SDD in total hospital cost (p < 0.0001), average direct costs (p < 0.0001) and average charges (p < 0.0016). SDD average hospital costs were $8699 (values in USD throughout) compared with $11 652 for POD 1 (p < 0.0001), and average SDD hospital charges were $85 506 compared with $97 008 for POD1 (p < 0.0016). The net revenue for SDD was $22 319 while for POD1 it was $26 173 (p = 0.14). Upon comparison of contribution margins (SDD $13 620 vs. POD1 $14 522), the difference was not statistically significant (p = 0.73). There were no identified statistically significant differences in operating room time, robotic console time, readmission rates or surgical complications. CONCLUSIONS: Amidst the pandemic-related constraints, we found that SDD was associated with lower hospital costs and comparable contribution margins compared with POD1. Additionally, the study was unable to identify any significant difference between operating time, readmissions, and surgical complications when performing SDD.

Ambulatory Endoscopic Submucosal Dissection for Gastrointestinal Neoplasms: Trends and Associated Factors in the United States.

Endoscopic submucosal dissection (ESD) is a minimally invasive treatment for superficial gastrointestinal (GI) cancers.1,2 ESD practice is expanding significantly in the United States and Western countries. This is attributed to a shorter hospital stay, better quality of life, and fewer adverse events compared with surgery. In the United States, ESD usually is performed and managed in an outpatient setting (ambulatory ESD) or with an overnight hospital stay. This practice is in contrast to Eastern Asian countries, where 3 to 5 days of hospital stay is a routine process for observation after ESD. A Swedish study showed that patients with well-selected colorectal neoplasms (median tumor size, 37 mm) could be managed safely in an outpatient setting after ESD.3 A North American multicenter ESD study also reported that ambulatory ESD was safe and feasible in selected cases (noninvasive cancers, no adverse events, high-volume endoscopists with short procedure time).4 However, procedural and technical aspects that enable safe outpatient management of patients after ESD need to be investigated.

Differences in total shoulder arthroplasty utilization and 30-day outcomes among White, Black, and Hispanic patients: do disparities exist in the outpatient setting?

BACKGROUND: In the United States, efforts to improve efficiency and reduce healthcare costs are shifting more total shoulder arthroplasty (TSA) surgeries to the outpatient setting. However, whether racial and ethnic disparities in access to high-quality outpatient TSA care exist remains to be elucidated. The purpose of this study was to assess racial/ethnic differences in relative outpatient TSA utilization and perioperative outcomes using a large national surgical database. METHODS: White, Black, and Hispanic patients who underwent TSA between 2017 and 2021 were identified from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Baseline demographic and clinical characteristics were collected, and rates of outpatient utilization, adverse events, readmission, reoperation, nonhome discharge, and mortality within 30 days of surgery were compared between racial/ethnic groups. Race/ethnicity-specific trends in utilization of outpatient TSA were assessed, and multivariable logistic regression was used to adjust for baseline demographic factors and comorbidities. RESULTS: A total of 21,186 patients were included, consisting of 19,135 (90.3%) White, 1093 (5.2%) Black, and 958 (4.5%) Hispanic patients and representing 17,649 (83.3%) inpatient and 3537 (16.7%) outpatient procedures. Black and Hispanic patients were generally younger and less healthy than White patients, yet incidences of complications, nonhome discharge, readmission, reoperation, and death within 30 days were similar across groups following outpatient TSA (P > .050 for all). Relative utilization of outpatient TSA increased by 28.7% among White patients, 29.5% among Black patients, and 38.6% among Hispanic patients (ptrend<0.001 for all). Hispanic patients were 64% more likely than White patients to undergo TSA as an outpatient procedure across the study period (OR: 1.64, 95% CI 1.40-1.92, P < .001), whereas odds did not differ between Black and White patients (OR: 1.04, 95% CI 0.87-1.23, P = .673). CONCLUSION: Relative utilization of outpatient TSA remains highest among Hispanic patients but has been significantly increasing across all racial and ethnic groups, now accounting for more than one-third of all TSA procedures. Considering outpatient TSA is associated with fewer complications and lower costs, increasing utilization may represent a promising avenue for reducing disparities in orthopedic shoulder surgery.