Predictors of Length of Stay and Discharge Disposition After Shoulder Arthroplasty

A Systematic Review

Jacob E. Berman, MBA; Ana Mata-Fink, MD; Hafiz F. Kassam, MD; Theodore A. Blaine, MD; David Kovacevic, MD


J Am Acad Orthop Surg. 2019;27(15):e696-e701. 

In This Article

Abstract and Introduction


Introduction: Identifying patient factors that affect length of stay (LOS) and discharge disposition after shoulder arthroplasty is key in managing patient expectations. In this systematic review, we identify patient-specific covariates that correlate with increased LOS and need for discharge to a facility.

Methods: We searched biomedical databases to identify associations between patient-specific factors and LOS and discharge disposition after shoulder arthroplasty. We included all studies involving hemiarthroplasty, anatomic shoulder arthroplasty, and reverse shoulder arthroplasty. Reported patient and provider factors were evaluated for their association with increased LOS and discharge to a facility.

Results: Twenty-two studies were identified. Age >65 years, female sex, obesity, and reverse shoulder arthroplasty were associated with extended LOS and correlated with discharge to a facility. Greater hospital and surgeon volume were associated with decreased LOS and decreased risk of discharge to a facility. Local injection of liposomal bupivacaine combined with intravenous dexamethasone was associated with reduced LOS.

Discussion: Patient factors affecting LOS and likelihood of discharge to a facility include age >65 years, female sex, diabetes, obesity, and reverse shoulder arthroplasty. These factors can be used to develop studies to preoperatively predict outcomes after shoulder arthroplasty and to help identify patients who may be at risk of prolonged postoperative admission.

Level of Evidence: Prognostic level IV


The volume of shoulder arthroplasty is increasing rapidly in the United States.[1] Each year, upwards of 53,000 people undergo shoulder arthroplasty, which represents an annual growth of approximately 10% per year, compared with total knee and total hip arthroplasty growth rates of 6% and 4.5%, respectively.[1,2] With this substantially increased volume, resource allocation has become a priority for our health system. There is now significant interest in decreasing length of stay and discharging patients to home to effectively manage healthcare resources.

Over the past 20 years, hospital length of stay after shoulder arthroplasty has decreased. In 1993, the average length of stay was 5.8 days; by 2007, it had dropped to 2.4 days.[1,3] Currently, many shoulder arthroplasty patients are discharged on the first postoperative day, and an increasing interest exists in providing safe outpatient shoulder arthroplasty. Outpatient hip and knee arthroplasty has been successfully implemented,[4,5] and studies have suggested that this can result in reduced costs.[6,7] Outpatient shoulder arthroplasty has been shown to be feasible for certain patients[8] and will also likely reduce healthcare costs and increase patient satisfaction. However, no significant research has been devoted to preoperatively identifying patients who are appropriate for outpatient shoulder arthroplasty.

A preoperative tool to effectively and accurately identify appropriate candidates is critical for transitioning to outpatient arthroplasty. Recently, investigators from a large health system developed an arthroplasty nomogram to identify hip and knee arthroplasty patients who require discharge to an extended care facility.[9] Knowing which patients require an increased length of stay or discharge to an extended care facility helps to make appropriate postoperative arrangements and identify patients who may be candidates for outpatient arthroplasty. Currently, no tools exist that can be used to predict length of stay and discharge disposition after shoulder arthroplasty. Identifying patient factors that affect postoperative length of stay and discharge disposition after shoulder arthroplasty will help manage patient expectations, identify patients who may qualify for outpatient surgery, and provide a framework for areas of appropriate resource allocation and cost savings.

The purpose of this review was to examine the preoperative patient and surgical factors associated with extended length of stay and subsequent need for discharge to a facility after shoulder arthroplasty. We hypothesized that patient-specific factors such as older age, female sex, and obesity will correlate with increased length of stay and that greater hospital and surgeon volume would decrease length of stay and the probability of discharge to a facility.