title: Safety and Outcomes of Inpatient Compared with Outpatient Surgical Procedures for Ankle Fractures.
abstract: BACKGROUND
  As the cost of health-care delivery rises in the era of bundled payments for care, there is an impetus toward minimizing hospitalization. Evidence to support the safety of open reduction and internal fixation (ORIF) of ankle fractures in the outpatient setting is largely anecdotal.
  
  
  METHODS
  Patients who underwent ORIF from 2005 to 2013 were identified via postoperative diagnoses of ankle fracture and Current Procedural Terminology codes; patients with open fractures and patients who were emergency cases were excluded. Patients undergoing inpatient and outpatient surgical procedures were propensity score-matched to reduce differences in the baseline characteristics. Primary tracked outcomes included medical and surgical complications, readmission, and reoperation within 30 days of the procedure. Binary logistic regression models were created that determined the risk-adjusted relationship between admission status and primary outcomes.
  
  
  RESULTS
  Outpatient surgical procedures were associated with lower rates of urinary tract infection (0.4% compared with 0.9%; p = 0.041), pneumonia (0.0% compared with 0.5%; p = 0.002), venous thromboembolic events (0.3% compared with 0.8%; p = 0.049), and bleeding requiring transfusion (0.1% compared with 0.6%; p = 0.012). Outpatient status was independently associated with reduced 30-day medical morbidity (odds ratio, 0.344 [95% confidence interval, 0.201 to 0.589]). No significant differences were uncovered with respect to surgical complications (p = 0.076), unplanned reoperations (p = 0.301), and unplanned readmissions (p = 0.358).
  
  
  CONCLUSIONS
  In patients with closed fractures and minimal comorbidities, outpatient ORIF was associated with reduced risk of select 30-day medical morbidity and no difference in surgical morbidity, reoperations, and readmissions relative to inpatient. Factors unaccounted for when creating matched cohorts may impact our results. Our findings lend reassurance to surgeons who defer admission for low-risk patients.
  
  
  METHODS
  Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
authors.affiliation: Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois c-qin@northwestern.edu.
authors.forename: Charles
authors.initials: C
authors.lastname: Qin
authors.affiliation: Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois robbertgdekker@gmail.com.
authors.forename: Robert G
authors.initials: RG
authors.lastname: Dekker
authors.affiliation: Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois joblough@northwestern.edu.
authors.forename: Jordan T
authors.initials: JT
authors.lastname: Blough
authors.affiliation: Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois Kadak259@gmail.com.
authors.forename: Anish R
authors.initials: AR
authors.lastname: Kadakia
mesh_terms: D000328:Adult; D000368:Aged; D000556:Ambulatory Surgical Procedures / Q000009:adverse effects*; D064386:Ankle Fractures / Q000601:surgery*; D005260:Female; D005593:Fracture Fixation, Internal / Q000009:adverse effects*; D006760:Hospitalization; D006801:Humans; D015994:Incidence; D007297:Inpatients; D008297:Male; D008875:Middle Aged; D010045:Outpatients; D011014:Pneumonia / Q000453:epidemiology* / Q000209:etiology; D011183:Postoperative Complications / Q000453:epidemiology; D012086:Reoperation; D012189:Retrospective Studies; D016896:Treatment Outcome; D014552:Urinary Tract Infections / Q000453:epidemiology* / Q000209:etiology