Yoeri Bemelmans

Chapter 7 116 be taken into account while interpreting the current results and emphasizes the need for large randomized controlled clinical trials comparing outpatient with inpatients pathways following hip and knee arthroplasty. Another factor that might impede the interpretation of the results is a lack of consistent use of the same definitions for complications/adverse events [54]. Some studies described (S)AEs in terms of surgical versusmedical complications [50], whereas others described minor versus major complications [32]. Scoring of complications was based on the authors’ interpretation or the availability of data in databases. Furthermore, the majority of (S)AEs occur within 4 days postoperatively [54]. Most inpatient pathways (consisting of fast-track recovery pathways) discharge patients within 2–3 days after surgery. This might explain why the current meta-analysis did not find differences in terms of overall complications and readmission rates, since both outpatients and inpatients are discharged within this time-frame. Another potential limitation could be the fact that the follow-up period for reporting complications and readmission rates varied between studies. Patients in the outpatient pathways improved equally postoperatively in terms of PROMs compared to patients in the inpatient pathways. Previous research did not find differences in the long-term (1 year) outcomes between these pathways [36]. PROMs are used to transform qualitative symptoms and limitations into quantitative data that can be compared over time, across patients, and benchmarked against different populations [55]. In the literature, the utilization of PROM tools varies strongly in and between measured domains following hip and knee arthroplasty, making it difficult to compare and interpret outcomes. The possible implementation of Patient-Reported Outcomes Measurement Information System (PROMIS®)—a systematic measurement systemapplying a standardizedmetric that is based on the normative data of the general population—is increasingly being researched in the orthopedic [55, 56] andmight allow for a better comparison of PROMs (also between different domains and populations) if adopted internationally in research. All studies on costs (and made a comparison between outpatient and inpatient pathways) included in this systematic review showed a total cost reduction in favor of outpatient pathways. All of these studies, however, treated costs differently which led to a wide range of outcome and made comparison difficult. One study assessed total charges to a patient’s insurance carrier (including surgical facility fees, OR supplies, hospital room facility, et cetera) and negotiated reimbursement [35]. Another study assessed total hospital charges because they found it impossible to assign actual costs to items such as nursing or therapist care and used fixed facility costs [5]. Two studies assessed direct costs (charges to the