Functional outcomes following inpatient versus outpatient hip or knee arthroplasty: a systematic review

Background:<br/>The prevalence of hip and knee osteoarthritis is climbing in line with increases in global lifespan, higher levels of obesity and a rise in youth sporting injuries. With osteoarthritis being the most commonly reported reason for undergoing lower limb arthroplasty it is not surprising that a subsequent surge in hip and knee arthroplasty procedures is predicted. As the economic burden associated with these procedures grows, optimisation of health care resources and sustainable perioperative delivery models are of critical consideration.<br/><br/>One strategy for improving cost containment is by reducing the length of hospital stay after a hip or knee arthroplasty procedure. The financial incentive along with surgical advances and rapid recovery protocols has led to the number of average days a patient stays after arthroplasty surgery decline. In line with this trend for reducing the length of stay, an outpatient or same-day discharge surgery service, that can be managed in a hospital or ambulatory surgery facility, is being offered to select lower limb arthroplasty patients with increasing frequency.<br/><br/>Purpose:<br/>To date, most studies have focused on the comparison between inpatient and outpatient settings assessing the safety and success of the surgery as defined by costs and feasibility, or complications and readmissions. Therefore, this systematic review aims to explore the available evidence for the effect on functional outcomes following inpatient versus outpatient hip or knee arthroplasty.<br/><br/>Methods:<br/>This systematic review adhered to the PRISMA guidelines and the protocol was prospectively registered (https://osf.io/8bfae/). An electronic search of PubMed, CINAHL and EMBASE databases was conducted to identify eligible studies. All studies investigating inpatient and outpatient comparator groups, for a population of patients undergoing hip or knee arthroplasty, that assessed one or more functional outcomes, were included. A methodological quality appraisal was undertaken for the final studies contained in this review. A narrative synthesis of results is described along with quantitative outcomes presented in tables and figures.<br/><br/>Results:<br/>Seven studies of overall good methodological quality containing 1,876 participants were included in this review. Study design varied, five provided a cohort study, one a randomised control trial and one a case–control study. Twenty different functional outcomes were utilised, of which 18 were patient-reported tools. Results of functional outcomes offered mixed support for inpatient and outpatient pathways.<br/><br/>Conclusion(s):<br/>The results of this systematic review suggest that outpatient or inpatient pathway selection for hip or knee arthroplasty should not be based on the superiority of functional outcomes alone. However, given there is growing evidence in support of an outpatient pathway in select patients with respect to cost savings and without any increase in complications, it could be proposed that an equivalency of post-operative function between the two settings makes same-day discharge favourable.<br/><br/>Implications:<br/>Research investigating outcomes of function and physical performance appears to be limited. If patient functional outcomes are equivalent or superior to those associated with an inpatient stay, then this combined with existing evidence to suggest the outpatient setting is both cost-effective and safe, adds further support for the uptake of the outpatient model in selected patients.<br/><br/>Keywords:<br/>Knee arthroplasty<br/>Hip arthroplasty<br/>Outpatient surgery<br/><br/>Funding acknowledgements:<br/>This systematic review did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.<br/><br/>Primary topic:<br/>Orthopaedics