Impact of the COVID-19 pandemic on shoulder arthroplasty: surgical trends and postoperative care pathway analysis.

BACKGROUND: COVID-19 triggered disruption in the conventional care pathways for many orthopedic procedures. The current study aims to quantify the impact of the COVID-19 pandemic on shoulder arthroplasty hospital surgical volume, trends in surgical case distribution, length of hospitalization, posthospital disposition, and 30-day readmission rates. METHODS: This study queried all Medicare (100% sample) fee-for-service beneficiaries who underwent a shoulder arthroplasty procedure (Diagnosis-Related Group code 483, Current Procedural Terminology code 23472) from January 1, 2019, to December 18, 2020. Fracture cases were separated from nonfracture cases, which were further subdivided into anatomic or reverse arthroplasty. Volume per 1000 Medicare beneficiaries was calculated from April to December 2020 and compared to the same months in 2019. Length of stay (LOS), discharged-home rate, and 30-day readmission for the same period were obtained. The yearly difference adjusted for age, sex, race (white vs. nonwhite), Centers for Medicare & Medicaid Services Hierarchical Condition Category risk score, month fixed effects, and Core-Based Statistical Area fixed effects, with standard errors clustered at the provider level, was calculated using a multivariate analysis (P < .05). RESULTS: A total of 49,412 and 41,554 total shoulder arthroplasty (TSA) cases were observed April through December for 2019 and 2020, respectively. There was an overall decrease in shoulder arthroplasty volume per 1000 Medicare beneficiaries by 14% (19% reduction in anatomic TSA, 13% reduction in reverse shoulder arthroplasty, and 3% reduction in fracture cases). LOS for all shoulder arthroplasty cases decreased by 16% (-0.27 days, P < .001) when adjusted for confounders. There was a 5% increase in the discharged-home rate (88.0% to 92.7%, P < .001), which was most prominent in fracture cases, with a 20% increase in discharged-home cases (65.0% to 73.4%, P < .001). There was no significant change in 30-day hospital readmission rates overall (P = .20) or when broken down by individual procedures. CONCLUSIONS: There was an overall decrease in shoulder arthroplasty volume per 1000 Medicare beneficiaries by 14% during the COVID-19 pandemic. A decrease in LOS and increase in the discharged-home rates was also observed with no significant change in 30-day hospital readmission, indicating that a shift toward an outpatient surgical model can be performed safely and efficiently and has the potential to provide value.

Outpatient Shoulder Arthroplasty Patient Selection, Patient Experience, and Cost Analyses: A Systematic Review.

BACKGROUND: The utilization of outpatient shoulder arthroplasty has been increasing. With increasing pressure to reduce costs, further underscored by the coronavirus (COVID-19) pandemic, many health-care organizations will move toward outpatient interventions to conserve inpatient resources. Although abundant literature has shown the advantages of outpatient total hip arthroplasty (THA) and total knee arthroplasty (TKA), there is a relative paucity describing outpatient shoulder arthroplasty. Thus, the purpose of this study was to summarize the peer-reviewed literature of outpatient shoulder arthroplasty with particular attention to patient selection, patient outcomes, and cost benefits. METHODS: The PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Embase databases were queried according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. All articles on outpatient shoulder arthroplasty were included. Data on patient selection, patient outcomes, and cost analyses were recorded. Patient outcomes, including complications, reoperations, and readmissions, were analyzed by weighted average. RESULTS: Twenty-three articles were included for analysis. There were 3 review articles and 20 studies with Level-III or IV evidence as assessed per The Journal of Bone & Joint Surgery Level of Evidence criteria. Patient selection was most often predicated on age <70 years, body mass index (BMI) <35 kg/m2, absence of active cardiopulmonary comorbidities, and presence of home support. Complications and readmissions were not common and either improved or were equivalent to those of inpatient shoulder arthroplasty. Patient satisfaction was high in studies of short-term and intermediate-term follow-up. The proposed cost benefit ranged from $747 to $53,202 with outpatient shoulder arthroplasty. CONCLUSIONS: The published literature to date supports outpatient shoulder arthroplasty as an effective, safe, and cost-reducing intervention with proper patient selection. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Mitigating Surgical Skill Decay in Orthopaedics Using Virtual Simulation Learning.

BACKGROUND: The COVID-19 pandemic has interrupted orthopaedic training structures for both surgeons and trainees. The concept of skill decay must be considered during inactivity of elective practice. The purpose of this study was to provide an evidence-based curriculum in association with immersive virtual reality (iVR) to prevent skill decay during periods of training cessation and beyond. METHODS: A review of pertinent literature for orthopaedic surgical skill decay was performed. Early experience by faculty instructors and residency and fellowship program directors was gathered from multiple institutions with experience in virtual training methods including iVR. A proposed curriculum for cognitive and manual skill acquisition during COVID-19 was produced from qualitative narrative group opinion. RESULTS: Skill decay can occur on the order of days to months and is dependent on the initial skill level. A novel curriculum for structured continuing medical education during and after periods of surgical disruption including e-learning, virtual meetings, and iVR simulators was produced from expert opinion and based on competency-based curriculum standards. CONCLUSION: Skill decay mitigation strategies should use best available evidence technologies and course structures that satisfy advanced learning concepts. The virtual curriculum including iVR simulators may provide cost-effective solutions to training.