Table. Comparison of length of hospital stay, discharge disposition, and complications in patients with same-day discharge (SDD) after shoulder arthroplasty before and after the onset of the COVID-19 pandemic (April 1, 2020)
Courtesy of Dylan Cannon, BS

AAOS Now

Published 8/2/2022
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Rebecca Araujo

More Patients Prefer Same-day Discharge Shoulder Arthroplasty

The COVID-19 pandemic spurred a significant increase in patients choosing same-day discharge (SDD) shoulder arthroplasty rather than an overnight stay in the hospital, according to a study presented at the AAOS 2022 Annual Meeting by Dylan Cannon, BS, medical student at the University of Oklahoma School of Medicine and clinical research fellow at Holy Cross Orthopedic Institute.

The option of early discharge after joint replacement surgery has risen in popularity as a way to reduce costs without negatively impacting patient recovery. Selected patients who can safely go home on the day of surgery may be given the choice of whether to stay overnight in the hospital.

The onset of the COVID-19 pandemic increased patient and physician interest in discharging eligible patients early and reducing time spent in the hospital. The goal of this study was to identify the change in utilization of SDD shoulder arthroplasty before and after the onset of the COVID-19 pandemic in patients who were eligible for early discharge.

Mr. Cannon told AAOS Now that he and his colleagues undertook the study in response to a recent trend at their institution of many more patients electing to go home from the hospital the same day. The team hypothesized that the pandemic marked a significant increase in the use of SDD.

The retrospective study included 370 patients treated by a single surgeon between August 2019 and December 2020. The population included patients who underwent either primary anatomic total shoulder arthroplasty (TSA) or reverse shoulder arthroplasty.

All patients received preoperative counseling regarding SDD and were given the option to spend the night in the hospital. The cutoff for “pre-COVID” was April 1, 2020, which was the date of a statewide ban on elective surgery in effect at the hospital. Each group (pre- and post-COVID) comprised 185 patients.

“This group of patients represents the 185 arthroplasty cases completed before the COVID-19 pandemic and the first 185 patients undergoing shoulder arthroplasty after the start of the pandemic,” the researchers noted in their study.

Collected data included patient demographics, medical history, length of stay, 30- and 90-day rates of readmission, and 90-day rates of emergency room and urgent care visits. The groups were similar in terms of age, BMI, gender, and Outpatient Arthroplasty Risk Assessment score. Statistical analyses included two-tailed student t-tests, chi-square tests, and Fischer’s exact test.

Interestingly, Mr. Cannon commented, comorbidities were similar between cohorts, “indicating that our findings were not related to healthier patients undergoing surgery during the pandemic,” he said.

The researchers found a significant difference in the type of surgery performed before and after the pandemic. Forty-four percent of the pre-COVID cohort underwent TSA, compared with 55 percent of patients post-COVID (P = 0.029).

Patients treated after the start of the pandemic were almost three times more likely to choose SDD arthroplasty (P <0.001). in the post-covid group, 158 patients (85.4 percent) opted to go home on the day of surgery. in the pre-covid group, only 64 patients (34.6 percent) chose that option. along with choice of sdd, discharge location was also significantly different before versus after the pandemic. ninety-nine percent (n="183)" of patients treated after the start of the pandemic were discharged home, compared with 94 percent (n="174)" of the pre-covid group.>

Despite the higher rate of early discharge, there were no differences between groups in rates of 30- and 90-day readmissions or 90-day emergency room/urgent care visits (Table).

“SDD continues to be a safe alternative for patients following shoulder arthroplasty,” Mr. Cannon commented.

Regarding limitations, Mr. Cannon noted, “These data come from a single high-volume shoulder surgeon at a single hospital. The results may not be replicable without changes in the culture of the institution.” Another limitation he noted is a lack of data on readmissions or emergency department visits from other hospitals and institutions.

Mr. Cannon concluded, “SDD following shoulder arthroplasty is proving to be safe for low-risk patients. The rate of SDD is likely to increase over time.”

Mr. Cannon’s coauthors of “A Comparison of Patient Same-day Discharge Selection following Shoulder Arthroplasty before and after the COVID-19 Pandemic” are Jose Rafael Garcia, BS; Adam Michael Watkins, BS; Hugo Cesar Rodriguez, DO, MBS; and Jonathan C. Levy, MD.

Rebecca Araujo is the managing editor of AAOS Now. She can be reached at raraujo@aaos.org.