scholarly journals 204 A Systematic Review of Clinical Outcomes for Outpatient vs Inpatient Shoulder Arthroplasty

2021 ◽  
Vol 108 (Supplement_6) ◽  
Author(s):  
E Perera ◽  
B Flood ◽  
K Madden ◽  
D Goel ◽  
T Leroux ◽  
...  
Keyword(s):  
Clinical Outcomes ◽  
Shoulder Arthroplasty ◽  
Outpatient Surgery ◽  
Care Pathway ◽  
Hospital Readmissions ◽  
Cost Effective ◽  
Outpatient Setting ◽  
Inpatient Setting ◽  
Operative Care ◽  
Significant Difference

Abstract Aim Outpatient shoulder arthroplasty is growing in popularity as a cost-effective and potentially equally safe alternative to inpatient arthroplasty. We investigated literature relating to outpatient shoulder arthroplasty, looking at clinical outcomes, complications, readmission, and cost compared to inpatient arthroplasty. Method We systematically searched Medline, Embase, PubMed using relevant search terms. Methodological quality of included studies was assessed using Methodological Index for Non-Randomised Studies score. Results We included 17 studies in our review with 11 included in the meta-analyses. A meta-analysis of hospital readmissions demonstrated that there was no statistically significant difference between outpatient and inpatient cohorts (OR = 0.89, 95% CI: 0.63-1.25, p = 0.49, I2=56%). Pooling results for all post-operative complications identified decreased complications in those undergoing outpatient surgery (OR = 0.70; 95% CI: 0.52-0.94, p = 0.02, I2=50%). No statistically significant difference was identified with respect to medical complications (OR = 0.86, 95% CI: 0.74-1.01, p = 0.07, I2=0%) or surgical complications (OR = 0.71, 95% CI: 0.45-1.12, p = 0.14, I2=26%). Considerable cost saving of between $3 614 – $53 202 (19.7 – 69.9%) per patient were present in the outpatient setting. Conclusions Shoulder arthroplasty in the outpatient setting is as safe as shoulder arthroplasty in the inpatient setting, with a significant reduction in cost. There is no demonstrable statistically significant difference with regards to readmissions between outpatient and inpatient shoulder arthroplasty. In the appropriately selected patient, outpatient shoulder arthroplasty is safe and cost-effective; however, we still need to work towards understanding who the appropriate patients are for this post-operative care pathway.

scholarly journals A systematic review of clinical outcomes for outpatient vs. inpatient shoulder arthroplasty

2021 ◽  
pp. 175857322110074
Author(s):  
Edward Perera ◽  
Breanne Flood ◽  
Kim Madden ◽  
Danny P Goel ◽  
Timothy Leroux ◽  
...  
Keyword(s):  
Systematic Review ◽  
Clinical Outcomes ◽  
Shoulder Arthroplasty ◽  
Outpatient Surgery ◽  
Hospital Readmissions ◽  
Outpatient Setting ◽  
Risk Of Bias ◽  
Cochrane Library ◽  
Inpatient Setting ◽  
Significant Difference

Background Outpatient shoulder arthroplasty is growing in popularity as a cost-effective and potentially equally safe alternative to inpatient arthroplasty. The aim of this study was to investigate literature relating to outpatient shoulder arthroplasty, looking at clinical outcomes, complications, readmission, and cost compared to inpatient arthroplasty. Methods We conducted a systematic review of Medline, Embase and Cochrane Library databases from inception to 6 April 2020. Methodological quality was assessed using MINORS and GRADE criteria. Results We included 17 studies, with 11 included in meta-analyses and 6 in narrative review. A meta-analysis of hospital readmissions demonstrated no statistically significant difference between outpatient and inpatient cohorts (OR = 0.89, p = 0.49). Pooled post-operative complications identified decreased complications in those undergoing outpatient surgery (OR = 0.70, p = 0.02). Considerable cost saving of between $3614 and $53,202 (19.7–69.9%) per patient were present in the outpatient setting. Overall study quality was low and presented a serious risk of bias. Discussion Shoulder arthroplasty in the outpatient setting appears to be as safe as shoulder arthroplasty in the inpatient setting, with a significant reduction in cost. However, this is based on low quality evidence and high risk of bias suggests further research is needed to substantiate these findings.

Is Outpatient Laparoscopic Cholecystectomy Safe and Cost-effective?

1999 ◽  
Vol 90 (6) ◽  
pp. 1746-1755. ◽  
Author(s):  
Lee A. Fleisher ◽  
Kelvin Yee ◽  
Keith D Lillemoe ◽  
Mark A. Talamini ◽  
Charles J. Yeo ◽  
...  
Keyword(s):  
Laparoscopic Cholecystectomy ◽  
Outpatient Surgery ◽  
Operating Time ◽  
Cost Savings ◽  
Postoperative Nausea And Vomiting ◽  
Cost Effective ◽  
Outpatient Setting ◽  
Postanesthesia Care Unit ◽  
Outpatient Basis ◽  
Home Setting

Background There is increasing pressure to perform traditional inpatient surgical procedures in an outpatient setting. The aim of the current trial was to determine the safety and cost savings of performing laparoscopic cholecystectomy in an outpatient setting using a "mock" outpatient setting. Methods Patients who were scheduled for laparoscopic cholecystectomy by four attending surgeons and for whom operating time was available in the outpatient center were studied. All patients received a standardized anesthetic, including ondansetron, and were discharged from the outpatient postanesthesia care unit if appropriate. At discharge, all patients were admitted to a clinical research center where they were observed in a "mock home" setting and monitored for complications that would have necessitated readmission. A decision analysis was created assuming all patients underwent outpatient surgery with either direct admission or discharge to home and readmission if complications developed. Results Of 99 patients who were enrolled in this study, 96 patients would have met the discharge criteria for home. No major complications were observed in these 96 patients. Eleven patients experienced postoperative nausea and vomiting, 3 of whom required an additional 24 h of hospital observation. In the decision model, the optimal strategy would be to perform the procedure on an outpatient basis and readmit patients only for complications, with an average baseline cost savings of $742/patient. Conclusions The results show that outpatient laparoscopic cholecystectomy is safe and cost-effective in selected patients, and that the mock home setting provides a means of studying the safety of transition of care.

scholarly journals Does Having a Rotator Cuff Repair Before Total Shoulder Arthroplasty Influence Outcomes?

2020 ◽  
Vol 8 (8) ◽  
pp. 232596712094277
Author(s):  
Brandon J. Erickson ◽  
Daphne Ling ◽  
Alexandra Wong ◽  
Joshua S. Dines ◽  
David M. Dines ◽  
...  
Keyword(s):  
Rotator Cuff ◽  
Clinical Outcomes ◽  
Shoulder Arthroplasty ◽  
Matched Control ◽  
Total Shoulder Arthroplasty ◽  
Control Group ◽  
Level Of Evidence ◽  
Significant Difference ◽  
History Of ◽  
Glenohumeral Osteoarthritis

Background: The number of rotator cuff repairs (RCRs) is increasing each year. Total shoulder arthroplasty (TSA) is a successful treatment option for patients with glenohumeral osteoarthritis with a functioning rotator cuff. Purpose/Hypothesis: The purposes of this study were to report the outcomes of TSA in patients with ipsilateral RCR and determine whether patients with a history of ipsilateral RCR who subsequently underwent TSA had differences in outcomes compared with matched controls who underwent TSA with no history of RCR. We hypothesized that patients with prior RCR will have significant improvements in clinical outcome scores, with no difference in outcomes after TSA compared with those with no prior RCR. Study Design: Cohort study; Level of evidence, 3. Methods: Patients eligible for inclusion were those with a history of prior RCR who underwent TSA at a single institution with a minimum 2-year follow-up between 2000 and 2015. Outcomes for this group, including American Shoulder and Elbow Surgeons (ASES) scores, were reported and then compared with a matched control group of patients who underwent TSA with no history of prior RCR. Controls were matched based on age, sex, and preoperative ASES score. Results: Overall, 14 patients (64% males; mean ± SD age, 65.1 ± 11.1 years) underwent prior ipsilateral RCR before TSA. ASES scores significantly improved from 42.9 to 78.5 at 2 years and to 86.6 at 5 years. When compared with 42 matched control patients (matched 1:3) who underwent TSA with no history of RCR, there was no significant difference in ASES scores at 2 years (78.5 vs 85.3; P = .19) and 5 years (86.6 vs 90.9; P = .72) between the prior RCR and no RCR groups. Conclusion: TSA in patients with a history of prior ipsilateral RCR led to significant improvements in clinical outcomes. No difference in clinical outcomes at 2 or 5 years after TSA was found between patients with and without a history of prior ipsilateral RCR.

Outcomes of day case shoulder replacement surgery in a stand-alone day care unit in the United Kingdom

2022 ◽  
pp. 175857322110708
Author(s):  
Mosab Elgalli ◽  
Jamie Hind ◽  
Ian Lahart ◽  
Gur Aziz Singh Sidhu ◽  
Sajjad Athar ◽  
...  
Keyword(s):  
Shoulder Arthroplasty ◽  
Care Pathway ◽  
Surgical Care ◽  
Operation Time ◽  
District General Hospital ◽  
Shoulder Replacement ◽  
Day Case ◽  
Replacement Surgery ◽  
Post Surgery ◽  
Significant Difference

Background: This review aims to compare the outcomes for day case shoulder replacement with in-patient shoulder replacement surgery in a district general hospital. Methods: Seventy-three patients had 82 shoulder arthroplasty procedures. Forty-six procedures were undertaken in a dedicated stand-alone day-case unit and 36 were undertaken as in-patient cases. Patient were followed up at 6 weeks, 6 months and annually. Results: There was no significant difference between the outcomes of shoulder arthroplasty procedures performed in the day case or in-patient settings making this a safe option for surgical care in a unit with an appropriate care pathway. Six complications in total were observed, three in each group. Operation time was statistically shorter for day cases by 25.1 min (95% CI - 36.5 to −13.7; d = −0.95, 95% CI −1.42 to 0.48). Estimated marginal means (EMM) revealed lower post-surgery oxford pain scores in day cases (EMM = 3.25, 95% CI 2.35, 4.16) compared with inpatients (EMM = 4.65, 95% CI 3.64 to 5.67). Constant shoulder scores were higher in day cases versus inpatients. Conclusion: Day case shoulder replacement is safe with comparable outcomes to routine inpatient care for patients up to ASA 3 classification with high satisfaction and excellent functional outcomes.

The Effect of Hospice on Hospital Admission and Readmission Rates: A Review

2018 ◽  
Vol 30 (3) ◽  
pp. 140-146
Author(s):  
Jennifer Treece ◽  
Mustafa Ghouse ◽  
Saima Rashid ◽  
Sowminya Arikapudi ◽  
Pratyaksha Sankhyan ◽  
...  
Keyword(s):  
Hospital Admission ◽  
Hospice Care ◽  
Symptom Control ◽  
Hospital Readmissions ◽  
Outpatient Setting ◽  
Inpatient Setting ◽  
Readmission Rates ◽  
Hospital Readmission Rates ◽  
The Impact

Symptom control may become challenging for terminally ill patients as they near the end of life. Patients often seek hospital admission to address symptoms, such as pain, nausea, vomiting, and restlessness. Alternatively, palliative medicine focuses on the control and mitigation of symptoms, while allowing patients to maintain their quality of life, whether in an outpatient or inpatient setting. Hospice care provides, in addition to inpatient care at a hospice facility or in a hospital, the option for patients to receive symptom management at home. This option for symptom control in the outpatient setting is essential to preventing repeated and expensive hospital readmissions. This article discusses the impact of hospice care on hospital readmission rates.

scholarly journals Development and implementation of a cardiac resynchronisation therapy care pathway: improved process and reduced resource use

2021 ◽  
Vol 10 (1) ◽  
pp. e001072
Author(s):  
Antonius Martinus Wilhelmus van Stipdonk ◽  
Stijn Schretlen ◽  
Wim Dohmen ◽  
Hans-Peter Brunner-LaRocca ◽  
Christian Knackstedt ◽  
...  
Keyword(s):  
Usual Care ◽  
Clinical Outcomes ◽  
Resource Use ◽  
Treatment Time ◽  
Care Pathway ◽  
Cardiac Resynchronisation Therapy ◽  
Total Hospitalisation ◽  
Significant Difference ◽  
Cardiac Resynchronisation ◽  
Resynchronisation Therapy

BackgroundCardiac resynchronisation therapy (CRT) requires intensive, complex and multidisciplinary care to maximize the clinical benefit. In current practice this is typically a task for highly specialised physicians. We report on a novel multidisciplinary, standardised CRT care pathway (CRT-CPW). Experienced clinicians developed a CPW with simple and broadly applicable aids based on clinical evidence and identified shortcomings in the current CRT care. The resulting CPW was implemented at the Maastricht University Medical Center, aiming at a transfer from heterogeneous physician-led care to standardized nurse-led care.MethodsTwo CRT patient cohorts were compared in this analysis. The benchmarked usual care cohort (2012–2014, 122 patients) was compared with the CRT-CPW cohort (2015–2017, 115 patients). The primary outcomes were process-related: number of physician consultations, nurse consultations, length of stay (LOS) at implantation and total hospitalisation days during 1-year follow-up, and referral-to-treatment time. Clinical outcomes were assessed to adress non-inferiority of quality of care.ResultsPatients in the CRT-CPW cohort consulted nurses and technicians significantly more often than patients in the usual care cohort (2.4±1.5 vs 1.7±2.0, p<0.0001 and 4.3±2.5 vs 3.7±1.5, p=0.063, respectively). Patients with CRT-CPW consulted physicians significantly less often (1.7±1.4 vs 2.6±2.1, p<0.001). Referral to treatment time was significantly reduced in the CRT-CPW group (23.6±18.4 vs 37.0±26.3 days, p=0.002). LOS at implantation and total hospitalisation days were significantly reduced in the CRT-CPW group (1.1±1.2 vs 1.5±0.7 days, p<0.0001 and 2.4±4.8 vs 4.8±9.3, p<0.0001, respectively). Clinical outcome analyses showed no significant difference in 12-month all-cause mortality and heart failure hospitalisations.ConclusionThe introduction of a novel CRT-CPW resulted in a successful transition of physician-led to nurse-led care, with a significantly reduced resource use and equal clinical outcomes. Future evaluations will focus on impact on outcomes versus costs, to evaluate cost-effectiveness of the CRT-CPW.

scholarly journals Outpatient Autotransplants for Persons with Multiple Sclerosis

Blood ◽  
2018 ◽  
Vol 132 (Supplement 1) ◽  
pp. 4618-4618 ◽  
Author(s):  
Gisela B. Gomez-Cruz ◽  
Robert Peter Gale ◽  
Juan Carlos Olivares Gazca ◽  
Andres Leon-Peña ◽  
David Gomez-Almaguer ◽  
...  
Keyword(s):  
Multiple Sclerosis ◽  
Bone Marrow ◽  
Blood Cells ◽  
Bone Marrow Cells ◽  
Early Death ◽  
Outpatient Setting ◽  
High Dose ◽  
Inpatient Setting ◽  
Significant Difference ◽  
Relapsing Remitting

Abstract Background. High-dose cyclophosphamide and a haematopoietic cell autotransplant is an effective therapy of multiple sclerosis (MS). This is often done in an inpatient setting using frozen blood cells either blood or bone marrow cells. Objective. Determine if this procedure can be safely and effectively simplified. Methods. We developed an autotransplant protocol actionable in an outpatient setting using refrigerated blood cells collected after giving cyclophosphamide, 50 mg/kg/d x 2 d and filgrastim, 10 μg/kg/d. A 2nd identical dose of cyclophosphamide was given 9 d later followed by infusion of blood cells stored at 4º C for 1-4 d. Subjects received rituximab after bone marrow recovery, 100 mg, every 2 mo for 1 y or rituximab, 1 g in 1 dose based on the subject's residence country (Figure 1). The co-primary outcomes were rate of bone marrow recovery and therapy-related mortality (TRM). Secondary outcomes included MS relapse-free survival (MS-RFS) and survival. Cumulative dose of cyclophosphamide was 200 mg/Kg Results. We treated 426 consecutive subjects. Median age was 47 y (range, 21-68 y). 145 (34%) were male. 84 (20%) had primary progressive MS, 173 (41%), relapsing remitting MS and 169 (39%), secondary progressive MS. Median blood cell storage time was 1 d (range, 1-4 d). Median intervals to granulocytes >0.5 x10E+9/L was 8 d (range, 2-12) and to platelets >20 x10E+/L, 8 days (range, 1-12). 412 subjects (96%) were treated as outpatients. Median follow-up is 6 mo (range, 3-30 mo). There was 1 death from TRM. In 304 subjects (71%) with data from neurologic evaluations ≥3 posttransplant median MS RFS is 27 mo (95% confidence interval [CI], 24, 30 mo). Estimated 1 y MS RFS is 85% (80, 90%) with no significant difference between the 3 MS variants. Median survival will exceed 30 mo. An unusual aspect of our study was giving two 2-d blocks of cyclophosphamide 8 days apart rather than 4 d continuously done for 3 reasons: (1) use of cyclophosphamide to mobilize blood cells for the autograft; (2) facilitate using a refrigerated rather than frozen autograft; and (3) decrease toxicity. Our finding of rapid bone marrow recovery using refrigerated grafts is like our experience in persons with plasma cell myeloma and lymphomas receiving high-dose therapy and an autotransplant. Conclusion. The strategy we developed was actionable in an outpatient setting with rapid recovery of granulocytes and platelets and only 1 early death. Estimated MS-RFS and survival were good. MS variant type did not correlate with MS-RFS or survival. Disclosures Gomez-Almaguer: AbbVie: Consultancy; Novartis: Consultancy.

Efficacy and Safety of Appetite-Stimulating Medications in the Inpatient Setting

2018 ◽  
Vol 53 (3) ◽  
pp. 261-267 ◽  
Author(s):  
Meredith L. Howard ◽  
Roya Hossaini ◽  
Catherine Tolar ◽  
Marian L. Gaviola
Keyword(s):  
Adverse Effects ◽  
Primary Outcome ◽  
Outpatient Setting ◽  
Hospitalized Patients ◽  
Inpatient Setting ◽  
Limited Information ◽  
Inclusion Criteria ◽  
Meal Intake ◽  
Significant Difference ◽  
Loss Of Appetite

Background: Hospitalized patients are subject to acute illness and stress which may impact appetite or weight. Loss of appetite may lead to increased morbidity or mortality. Medications such as dronabinol, megestrol, and mirtazapine are used for weight gain in the outpatient setting; however, there is limited information about safety or effectiveness when initiated inpatient. Objectives: To analyze the effectiveness and safety of appetite-stimulating medications in hospitalized patients. Methods: This was a retrospective cohort study of hospitalized patients initiated on dronabinol, megestrol, or mirtazapine for appetite. The primary outcome was change in meal intake between drug initiation and discontinuation. Secondary outcomes included documented improvement in appetite, change in weight and various laboratory parameters, and incidence of adverse effects. Results: A total of 38 patients met inclusion criteria, and mirtazapine was most commonly used (42%). There was no significant difference between groups of appetite-stimulating medications with regard to mean change in meal intake, weight, albumin, or documented improvement in diet. Within groups, each agent showed numerical improvement in percentage meal intake, with a mean change from initiation to discontinuation of 17.12%. Almost half (48%) of the patients experienced improvement in diet after the start of medications. No serious adverse effects were observed. Conclusion and Relevance: In inpatients, there was no difference in change in meal intake or weight between dronabinol, megestrol, or mirtazapine, but they may show numerical improvements in meal intake. To our knowledge, this is the first study to evaluate the use of dronabinol, megestrol, and mirtazapine initiated in the inpatient setting.

scholarly journals Safety and Cost Effectiveness of Chimeric Antigen Receptor T Cell Therapy in the Outpatient Setting

Blood ◽  
2021 ◽  
Vol 138 (Supplement 1) ◽  
pp. 2823-2823
Author(s):  
Moazzam Shahzad ◽  
Muhammad Salman Faisal ◽  
Ernie Shippey ◽  
Ali Hussain ◽  
Clint Divine ◽  
...  
Keyword(s):  
Adverse Effects ◽  
Adverse Events ◽  
Board Of Directors ◽  
Research Funding ◽  
Cost Effective ◽  
Outpatient Setting ◽  
Inpatient Setting ◽  
Advisory Committees ◽  
Outpatient Group ◽  
Car T

Abstract Introduction Since the commercial approval of chimeric antigen receptor T cell (CAR-T) therapies, administration and toxicity monitoring have largely been in an inpatient setting due to the risk of significant toxicities such as cytokine release syndrome (CRS) and neurotoxicity in the first 30 days. Administration in the outpatient setting can be safe and cost-effective. Here we report the cost savings and adverse events of CAR-T in an outpatient setting as compared to the inpatient setting. Methods Cost differences of the commercial CD19 CAR-T axicabtagene ciloleucel (axi-cel) and tisangenlecleucel (tisa-cel) among inpatient and outpatient settings in 2020 were investigated using the Vizient Database®. Cost analysis for both settings was done for the initial 30 days post-CAR-T infusion. There were no billing codes for CRS and neurotoxicity till 2021. Clinical surrogates such as fever, hypotension, hypoxia, sepsis were used for CRS while febrile convulsion not otherwise specified (NOS), febrile seizure NOS, altered mental status, somnolence, stupor, and coma were used for neurotoxicity. ICD 10 codes for adverse effects were also used. Results In 2017-2020, there were 81 organizations in the database that performed CAR-T procedures. In 2020, there were 1369 inpatient and 71 outpatient encounters, which were analyzed for cost and adverse events. (Table 1) The incidence of CRS was 43.2% (n=592) and 40.8% (n=29) in inpatient and outpatient groups, while that of neurotoxicity was 37.3% (n=511) and 29.6% (n=21) respectively. For cost analysis, we included the 16 centers (22% of all centers) that offered both inpatient and outpatient administration in 2020. Median inpatient cost was $397,610 ($346,550-$650,749) and median outpatient group cost was $243,050 ($204,344-$408,467). An analysis of variance (ANOVA) was run between inpatient and outpatient cases was found to be significant (P&lt;0.0001). (Table 2) (Figure 1) (Figure 2) Conclusion As the field of CAR-T therapy continues to grow, outpatient programs are likely to increase. Incidence of adverse effects was lower in the outpatient group, likely patient selection effect. This data suggests that outpatient CAR-T therapy is feasible cost-effective and has the potential to grow and improve value. While it appears to be an attractive option, there is a need for more studies on patient selection and creating a robust outpatient infrastructure is needed. Figure 1 Figure 1. Disclosures Mahmoudjafari: Incyte: Membership on an entity's Board of Directors or advisory committees; Omeros: Membership on an entity's Board of Directors or advisory committees; GSK: Membership on an entity's Board of Directors or advisory committees. McGuirk: EcoR1 Capital: Consultancy; Novartis: Research Funding; Fresenius Biotech: Research Funding; Novartis: Research Funding; Astelllas Pharma: Research Funding; Bellicum Pharmaceuticals: Research Funding; Kite/ Gilead: Consultancy, Honoraria, Other: travel accommodations, expense, Kite a Gilead company, Research Funding, Speakers Bureau; Gamida Cell: Research Funding; Magenta Therapeutics: Consultancy, Honoraria, Research Funding; Juno Therapeutics: Consultancy, Honoraria, Research Funding; Allovir: Consultancy, Honoraria, Research Funding; Pluristem Therapeutics: Research Funding.

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