J Shoulder Elbow Surg (2018) 27, S82–S87

www.elsevier.com/locate/ymse

Surgeons’ experience and perceived barriers with

outpatient shoulder arthroplasty
Tyler J. Brolin, MD, Ryan M. Cox, BS, Benjamin M. Zmistowski, MD,
Surena Namdari, MD, MSc, Gerald R. Williams, MD, Joseph A. Abboud, MD*

Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA

Background: Recently, outpatient total shoulder arthroplasty (TSA) has been proposed as a safe and cost-
effective alternative to the inpatient setting. This study evaluated the expert shoulder surgeon’s experience
with and perceived barriers to outpatient TSA.
Methods: A secure web application was used to perform an online survey of 484 active American Shoul-
der and Elbow Surgeons members. The survey assessed surgeon practice demographics, experience with
TSA/outpatient TSA, and perceived barriers to successful outpatient TSA. Simple descriptive statistics were
performed to analyze the cohort. To identify differences between surgeons performing and not perform-
ing outpatient TSA, the Student t test and χ2 test were used in bivariate analysis. P < .05 was used for
statistical significance.
Results: Of the 179 (37.0%) complete responses received, 20.7% perform outpatient TSA; of those, 78.4%
reported an “excellent” experience. Outpatient surgeons were more likely to reside in the southern United
States (P = .05) and performed a higher volume of TSAs annually (P = .03). Surgeons not performing out-
patient TSA were more concerned with the potential of medical complications (P = .04). Perceived lack
of experience (P = .002), low volume (P = .008), insurance contracts (P = .003), and reimbursement (P = .04)
were less important barriers compared with outpatient TSA surgeons.
Conclusions: Less than 25% of shoulder surgeons who completed survey are performing outpatient TSA,
and those that do report an overall excellent experience. Volume of TSAs performed and practice loca-
tion appear to play roles in the decision to perform outpatient TSA. As surgeons become more comfortable
with outpatient TSA, there is a shift from concerns about medical complications to concerns about
reimbursement.
Level of evidence: Survey Study; Experts
© 2018 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.
Keywords: Shoulder arthroplasty; outpatient shoulder arthroplasty; outpatient joint arthroplasty; surgeon
satisfaction; cost-effectiveness; survey

The health care environment, which is rapidly evolving,

This study was approved through Thomas Jefferson University’s Institu-
tional Review Board Control #16E.686.
*Reprint requests: Joseph A. Abboud, MD, The Rothman Institute, 925
Chestnut St., Philadelphia, PA 19107, USA.
E-mail address: abboudj@gmail.com (J.A. Abboud).
has seen health care policy makers place increased atten-
tion on the costs associated with the delivery of health care.
Total shoulder arthroplasty (TSA) is a successful operation
to restore function and provide pain relief for patients with
end-stage degenerative conditions of the glenohumeral joint.
The demand for TSA continues to see tremendous growth,

1058-2746/$ - see front matter © 2018 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.
https://doi.org/10.1016/j.jse.2018.01.018
ASES outpatient TSA survey
which translates to increased health care-related expenditures.6
Surgeons have thus found new pathways to deliver safe, high-
quality, efficient, and cost-effective health care. Most notably,
outpatient TSA has become an increasingly viable option com-
pared with routine inpatient hospital admission in appropriately
selected patients.3,7,9
TSA has traditionally remained an inpatient procedure due
to concerns over pain control, blood loss, and the potential
of postoperative complications. However, improvement in sur-
gical techniques, pain management strategies, and perioperative
management have led to declining lengths of stay without com-
promising patient satisfaction or safety.7 Recent reports have
shown the average length of stay after TSA is 1.1 to 2.2 days.3,7
Our experience is that most patients spend a single night in
the hospital and are able to be discharged home the follow-
ing day. This has led to a natural transition to outpatient TSA
in appropriately selected patients.
Three recent reports have documented the safety of out-
patient TSA compared with traditional inpatient hospital
admission, with no increase in the readmission or compli-
cation rates.3,4,9 A recent report from Cancienne et al4 noted
that outpatient TSA may be cost-effective as well. The authors
found that the transition to an outpatient setting resulted in
a mean cost-reduction of $3618 per patient in diagnostic-
related group reimbursements.
Surgeons face an important balance between implement-
ing potential cost-saving measures without jeopardizing safety
or outcomes. This is highlighted in the recent introduction
of bundled-payment programs that place increased financial
responsibility on the surgeon for any complications or read-
mission within the 90-day episode of care. The number of
outpatient TSAs performed increased by 107% from 2011 to
2014 but still only accounts for 2.4% of all TSAs performed.4,9
We sought to investigate the expert shoulder surgeon’s ex-
perience with outpatient TSA and perceived barriers to
successful implementation of an outpatient TSA program.
Materials and methods
Survey population
An online survey was distributed to 484 active American Shoulder
and Elbow Surgeons (ASES) members who had email addresses on
file as of January 2017. Study data were collected and managed using
REDCap (Research Electronic Data Capture; Vanderbilt Universi-
ty, Nashville, TN, USA) electronic data capture tools. A link to the
survey was distributed by email on January 11, 2017, and again on
February 1, 2017. Only complete survey responses were included
for analysis.
Survey detail
The survey included 45 questions and was designed to assess 4 areas:
surgeon practice demographics, overall experience with shoulder ar-
throplasty, the surgeon’s experience with outpatient TSA, and what
each surgeon defined as major hurdles to successful outpatient TSA.
S83
The practice demographic questions regarded fellowship training,
place and setting of practice, number of years in practice, and any
ownership involvement in hospitals or ambulatory surgery centers.
Shoulder arthroplasty experience was assessed by asking each
surgeon how many arthroplasties he or she performed each year,
average length of stay after shoulder arthroplasty, average age of
patients receiving shoulder arthroplasty, use of physical therapy post-
operatively, and concerns about health care cost-effectiveness.
Surgeons were then asked whether they perform outpatient TSA.
If so, they were questioned on the relative percentage of outpa-
tient cases performed, satisfaction with outpatient TSA, concerns,
and whether they use nurse navigators or screening question-
naires. Finally, all surgeons were asked to rate 14 potential barriers
to successful outpatient TSA from 1 (minor hurdle) to 10 (major
hurdle). The 14 potential barriers were formulated after querying
the shoulder and elbow surgeons within our practice (see Appendix 1).
Statistical analysis
The survey responses were collected and tabulated anonymously with
use of available software provided by the online survey system. Simple
descriptive statistics were performed to analyze the cohort. To iden-
tify differences in survey results for surgeons who did and did not
perform outpatient TSA, the Student t test and χ2 test were used in
bivariate analysis for continuous and categoric variables, respec-
tively. A threshold of P < .05 was used for statistical significance.
Results
Respondents’ characteristics
The entire survey was completed by 179 of 484 members
(37.0%). Of the survey participants, 48.0% (86 of 179) were
less than 10 years, 27.4% (49 of 179) were 10 to 20 years,
and 24.6% (44 of 179) were greater than 20 years into prac-
tice. Most participants were shoulder and elbow (78.2% [140
of 179]) or sports medicine (21.8% [39 of 179]) fellowship
trained. The practice setting for the participating surgeons in-
cluded 38.0% (68 of 179) group-owned private practice, 10.1%
(18 of 179) hospital-owned private practice, 33.5% (60 of 179)
academic university hospital, and 18.4% (33 of 179) academic-
private practice. Of the respondents, 10.1% (18 of 179)
reported hospital ownership interest, and 39.1% (70 of 179)
reported surgery center ownership interest. A breakdown of
practice setting and of ownership interest in a hospital or
surgery center between surgeons that do and do not perform
outpatient TSA is reported in Table I.
Shoulder arthroplasty practice
Most surgeons (64.8% [116 of 179]) preformed more than
50 shoulder arthroplasties per year. The average age of shoul-
der arthroplasty patients was between 60 and 70 years for
88.3% (158 of 179) of surgeons. The average length of stay
was less than 1.5 days for 70.9% (127 of 179) of the par-
ticipating surgeons. Overall, 37 of the 179 participants (20.7%)
performed outpatient TSAs, and 31.3% (56 of 179)
S84 T.J. Brolin et al.

routinely placed a drain after shoulder arthroplasty. Home or

Table I Practice characteristics, including practice setting and ownership interests in a hospital or surgery center, for surgeons performing outpatient total shoulder arthroplasty

19 (51.4)
90 (63.4)
outpatient physical therapy was used by 88.8% (159 of 179)
of surgeons for anatomic TSA and 73.7% (132 of 179) for

No
reverse TSA.

ASC ownership Cost-consciousness

18 (48.6)
52 (36.6)
0.18
Yes
When the respondents were asked how much concern ortho-
pedic surgeons should have with the cost of a given procedure,
1.7% (3 of 179) responded no concern, 17.9% (32 of 179)
35 (94.6)
126 (88.7)
mild concern, 51.4% (92 of 179) moderate concern, and 29.1%
(52 of 179) very concerned. If outpatient TSA was shown to
be cost-effective, 78.8% (141 of 179) would be more inter-
Hospital ownership
No

ested in performing TSA in an outpatient setting. If

reimbursement was decreased when performing outpatient
TSA, 62.6% (112 of 179) of respondents said they would not
16 (11.3)
2 (5.4)

be interested.
0.29
Yes

Outpatient TSA experience

Academic university

Of those surgeons performing outpatient TSA, 29.7% (11 of

37) perform at least 25% of their TSAs as an outpatient pro-
cedure, 35.1% (13 of 37) use a nurse navigator in the process,
employee

7 (32.4)
48 (33.8)

and 51.4% (19 of 37) use a screening questionnaire. All sur-

geons performing outpatient shoulder arthroplasty reported
a good or excellent overall experience with outpatient TSA.
Specifically, 78.4% (29 of 37) of those performing outpa-
tient shoulder arthroplasty, 16.2% of all respondents, reported
Academic-affiliated

an excellent experience overall.

Concerns about and barriers to outpatient TSA

6 (16.2)
27 (19)

Most of the respondents (97.8% [175 of 179]) felt that out-

vs. those that perform total shoulder arthroplasty as an inpatient only

patient TSA was feasible. Despite this, shoulder arthroplasty

remained an inpatient procedure due to medical comorbidities
for 70.9% (127 of 179) of surgeons, invasiveness of the pro-
Hospital-owned

cedure for 51.4% (92 of 179), and pain control for 33.5% (60
ASC, ambulatory surgery center; TSA, total shoulder arthroplasty.

of 179). Of the participating surgeons, 78.2% (140 of 179)

17 (12.0)
1 (2.7)

indicated that their level of comfort was not an issue with dis-
charging a patient the same day after shoulder arthroplasty.
The 5 biggest hurdles for surgeons not performing outpa-
tient TSA were patient comorbidities, patient social support,
Practice setting
Private practice

concern for medical complication, readmission risk, and patient

Group-owned

age (Fig. 1). The 5 biggest hurdles for surgeons already per-
18 (48.6)
50 (35.2)

forming outpatient TSA were patient comorbidities, insurance

0.11

contracts, patient social support, patient age, and concern for

medical complication.
TSA surgeon, No. (%)

Comparing surgeons who do and do not perform

outpatient TSA
Inpatient only
Outpatient

When the practice characteristics of surgeons who do and do

Variable

P value

not perform outpatient TSA were compared, outpatient TSA

surgeons perform a higher volume of TSAs annually (37.8%
vs. 30.2% performed greater than 100 TSAs annually and
ASES outpatient TSA survey
Figure 1 Perceived hurdles to successful outpatient total shoulder arthroplasty (TSA) of surgeons currently performing outpatient TSA
compared with surgeons performing TSA strictly as an inpatient procedure. The range bars show the standard deviation. *P < .05.
16.2% vs. 5.6% greater than 150 annually; P = .03), were more
likely residing in the South (P = .05), and were less likely to
use both routine home and therapist-directed therapy (8.1%
vs. 23.9% used in greater than 75% of cases; P = .03). Sur-
geons who do not perform outpatient TSA were less likely
to cite reimbursement (17.6% vs. 43.2%; P = .002) as a reason
why TSA has remained an inpatient procedure. These sur-
geons also reported that lack of experience (average: 2.4 of
10 vs. 4.0 of 10; P = .002), low volume (2.6 vs. 4.1; P = .008),
insurance contracts (4.6 vs. 6.3; P = .003), and concern about
decreasing procedure reimbursement (3.4 vs. 4.5; P = .04) had
low ranks in importance as a hurdle to outpatient TSA com-
pared with outpatient TSA surgeons.
Discussion
The purpose of this study was to assess surgeon’s experi-
ence with outpatient TSA, describe the practice characteristics
of outpatient TSA surgeons, and to try to identify barriers to
successful implementation of an outpatient TSA program. We
believe this study is relevant to all shoulder arthroplasty sur-
geons because it reflects the practice demographics and
S85
opinions of ASES members, and because most of the respon-
dents have shoulder and elbow fellowship training (78.2%),
perform greater than 50 shoulder arthroplasties per year
(64.8%), and come from a variety of practice settings. We
also believe this is an important topic because the number
of outpatient shoulder arthroplasties performed each year is
rapidly increasing without previous reports documenting sur-
geons’ satisfaction after implementing an outpatient TSA
program.4 Outpatient TSA still represents a significant mi-
nority (2.4%) of shoulder arthroplasties performed each year,
and although TSA remains an inpatient procedure for most
patients due to age, medical comorbidities, and available
support system, there are likely a number of patients in each
surgeon’s practice who would be appropriate candidates for
outpatient TSA.9 We hope that identifying barriers to the ini-
tiation or success of outpatient TSA will allow shoulder
surgeons to address these through education and future studies
to benefit surgeons who wish to transition future patients to
the outpatient setting.
Of the respondents, 20.7% of surgeons perform outpa-
tient TSA. Not surprisingly, practice location and volume of
shoulder arthroplasties performed each year played a role
in the decision to pursue an outpatient TSA program. Differing
S86
regions and states within the United States have varying po-
litical atmospheres affecting the delivery of health care, which
may account for more outpatient TSA surgeons practicing in
the southern United States. We found, however, no differ-
ence between inpatient and outpatient TSA surgeons regarding
practice type or presence of ownership interests in a hospi-
tal or surgery center. Also, outpatient TSA surgeons who
completed this survey performed higher volumes of shoul-
der arthroplasties. This likely reflects their increased comfort
with the procedure.
It is imperative that the surgeon be facile with shoulder
arthroplasty before initiating an outpatient TSA program,
because previous studies have shown increased operative times
lead to increased complication rates after TSA.2,13 Those out-
patient TSA surgeons completing the survey seemed to agree,
because they were more likely to perceive a lack of TSA ex-
perience and low TSA case volume as barriers compared with
surgeons who do not perform TSA in an ambulatory setting.
From a logistical standpoint, ambulatory surgery centers and
specialty hospitals may have limited implants and instru-
ments available at the surgeon’s disposal. This makes the ability
to perform a TSA in an efficient and reproducible manner a
prerequisite to outpatient TSA. Despite these concerns, sur-
geons performing outpatient TSAs had high levels of
satisfaction, with 78.4% reporting an excellent experience in
this questionnaire.
The biggest hurdles to outpatient TSA for both groups of
surgeons revolved around the patient’s medical comorbidities
and available support system. One of the major concerns
regarding outpatient joint arthroplasty is whether potential
complications will occur in an unmonitored home
environment, leading to increased morbidity and hospital
readmissions.
Appropriate patient selection is of paramount impor-
tance, with several previous studies increasing our
understanding of risk factors for increased morbidity, mor-
tality, and readmission after total joint arthroplasty.2,5,10,11,13,14
These studies are critical to our ability to appropriately select
patients for ambulatory TSA. From the available literature,
consistent risk factors for increased morbidity, mortality, and
readmission include coronary artery disease, previous cardiac
events, chronic lung disease, peripheral vascular disease, in-
creased comorbidity index, and increased age.2,5,10,11,13,14
Accurately predicting which patients are able to be dis-
charged is necessary. Unplanned overnight stays or transfers
to a hospital increase the episode-of-care costs, decrease patient
satisfaction, and may compromise patient safety.
This study found concern over medical complications was
a significantly larger hurdle to outpatient TSA for surgeons
who do not currently perform outpatient TSA. Surprisingly,
patients of 70.9% of surgeons had an average length of stay
of less than 1.5 days after shoulder arthroplasty. Courtney et al5
found that 84% of complications requiring physician inter-
vention after total hip and knee arthroplasty occurred greater
than 24 hours postoperatively. This leads us to believe that
the vast majority of complications will occur after dis-
T.J. Brolin et al.
charge, regardless of the choice between routine hospital
admission and outpatient surgery.
Three previous reports on the safety of outpatient shoul-
der arthroplasty did not show an increase in complications
or readmissions compared with traditional inpatient TSA.3,4,9
Brolin et al3 matched a cohort of 30 patients undergoing tra-
ditional inpatient TSA to those undergoing outpatient TSA
at a freestanding ambulatory surgery center. The authors
found similar results, including no difference in 90-day
episode-of-care measures (complications, readmissions, or
reoperations). Our study suggests that after experience with
outpatient TSA, surgeons’ concerns shift from that of the po-
tential for medical complications to concerns over
reimbursement.
This study has certain limitations. Inherent to survey studies
is the moderate response rate of 37.0%. However, this is con-
sistent with previously published survey studies on shoulder
pathology that have reported response rates from 29.8% to
40%.1,8,12 We do believe that with our response rate that the
findings of this study are reflective of the general practice char-
acteristics of shoulder surgeons within the ASES.
The survey used in this study was not formally vali-
dated, was created after discussion with shoulder and elbow
surgeons from a large combined academic-private practice,
and may not reflect the actual concerns of all shoulder sur-
geons. For example, it was brought to our attention after our
survey was dispersed that 1 surgeon was particularly con-
cerned about patients not receiving the full 24 hours of
prophylactic intravenous antibiotics. This can be alleviated
by using 24-hour cephalosporins.
Lastly, the responses to our study may represent a selec-
tion bias and may not be representative of the views of most
ASES active members or those performing the majority of
TSAs.
Conclusion
Almost all of the surgeons surveyed believed that outpa-
tient TSA was feasible. Although less than one-quarter of
shoulder surgeons are performing outpatient TSA, those
that do report an overall excellent experience. The volume
of shoulder arthroplasties performed and practice loca-
tion appear to play roles in the decision to pursue an
outpatient TSA program. As surgeons become more com-
fortable with outpatient TSA, there is a shift from concerns
over medical complications to concerns over
reimbursement.
Disclaimer
The authors, their immediate families, and any research
foundations with which they are affiliated have not re-
ceived any financial payments or other benefits from any
commercial entity related to the subject of this article.
ASES outpatient TSA survey
Supplementary data
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.jse.2018.01.018.
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