Safety and Outcomes of Inpatient Compared with Outpatient Procedures for Elective Orthopaedic Foot and Ankle Surgery
Authors: Shah Ashish , Huntley Samuel , Patel Harshadkumar , Naranje Sameer , Lee Sung , Pinto Martim , Gutman Ilya , Cantrell Colin , Shrestha Kevin 
Published: September 2018

Category: Ankle Introduction/Purpose: With increasing implementation of the bundled payment model and meteoric rise in healthcare prices over the past decade, efforts to minimize unnecessary costs are highly warranted. One potential method to do this is by performing foot and ankle surgery on patients either in an appropriate inpatient or outpatient setting. There is evidence suggesting that outpatient orthopaedic foot and ankle surgery for ankle fractures leads to lower risk of 30-day medical morbidities, reoperation, and admissions as compared to inpatient surgeries. The purpose of this study is to compare the inpatient versus outpatient outcomes of patients undergoing elective orthopaedic foot and ankle surgery using a large national database. Methods: Data from the National Surgical Quality Improvement Program (NSQIP) years 2005-2015 were used in this study. There were 216 CPT codes specific to orthopaedic foot and ankle surgery queried for inclusion in the analysis, 36 of which were identified in the database. CPT codes representing ORIF of ankle fractures were excluded. These codes were manually reviewed by a licensed orthopaedic foot and ankle surgeon to confirm their elective nature, reducing the number of codes to 30. Demographic, comorbidity, and outcome variables were calculated and stratified by inpatient versus outpatient status. Significant differences in these variables were evaluated using ANOVA for continuous variables and Pearson’s Chi-Square for categorical variables. There was a total of 7,672 cases identified. Results: The most common elective inpatient procedures were transmetatarsal amputation (57.9%), total ankle arthroplasty (13.0%), and midtarsal amputation (5.2%). The most common elective outpatient procedures were collateral ligamentous repair (15.8%), transmetatarsal amputation (10.7%), and extensor tendon repair (8.7%). As compared to patients receiving outpatient treatment, patients who received inpatient treatment for elective foot and ankle surgeries were significantly older, male, had lower BMI, and were more likely to smoke. Inpatients were also more likely to receive general anesthesia, have shorter operative times, and have functional limitations (p<0.05). Inpatients were more likely to suffer from various complications, including surgical site infection, pneumonia, unplanned intubation, renal insufficiency, acute renal failure, urinary tract infections, myocardial infarction, cardiac arrest, stroke, transfusions, sepsis, and reoperation (p<0.05). Conclusion: Our results show that outpatient procedures for elective foot and ankle surgery were significantly safer than inpatient procedures in regard to complication profiles. However, the inpatients who received surgery were significantly older than the outpatients, which may explain the described findings. Additional advanced regression modeling is currently underway to examine the multivariable associations between inpatient status and total hospital costs.