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


Both patient and surgical factors affect hospital length of stay and likelihood of discharge to a facility after shoulder arthroplasty. Our hypotheses were confirmed; older age, female sex, and several major medical comorbidities were all clearly associated with an extended length of stay and an increased likelihood of discharge to a facility (Table 4, Supplemental Digital Content 4, These findings correlate well with the previously published hip and knee arthroplasty nomogram for discharge to a facility.[9]

Hospital and surgeon volume were also important, with increased hospital and surgeon volume correlating with a decreased length of stay and decreased likelihood of discharge to a facility. Surgical factors such as anesthesia type and use of new pain relief techniques were also correlated with length of stay and discharge disposition with general anesthesia and peripheral blocks reducing length of stay and the use of a continuous interscalene brachial plexus blockade having a mixed, and therefore, unclear effect. Taken together and explored further, this information can be useful for patients and caregivers because they make decisions about their care before surgery.

Although reverse TSA seems to correlate with an increased likelihood of discharge to a facility, the effect of type of shoulder arthroplasty on length of stay is not clear, with one study suggesting no difference in length of stay and another reporting an increased length of stay. These conflicting results may be due to confounding of other factors such as the fact that reverse shoulder arthroplasty is more commonly performed in older patients and the indications for the procedure are continually expanding.

Limitations to this systematic review involve the included studies. Despite 22 studies meeting the inclusion criteria, few studies examined the same factors and few used the same referent group for ORs. This phenomenon made comparing associations between patient and surgical factors and length of stay and discharge disposition difficult. In addition, despite efforts to minimize duplicate data using exclusion criteria, some studies used the same database over a similar period, which may make some results more homogeneous and result in double counting of records. However, this systematic review included a large number of procedures, and the results are consistent with other studies in the arthroplasty literature.[9,30,31]

Few studies have shown that outpatient shoulder arthroplasty is a safe alternative to inpatient shoulder arthroplasty for select patients, with no significant difference in complications or readmission rates.[8,32] The key is identifying and selecting appropriate patients. Investigators studying the feasibility of outpatient shoulder arthroplasty had anesthesiologists determine the patients appropriate for outpatient surgery.[8] Similar to an arthroplasty nomogram created for lower extremity joint arthroplasty, patient and surgical factors can be incorporated into a predictive tool for shoulder arthroplasty.[9] The findings from this systematic review suggest that it should be possible for the surgeon to preoperatively predict which patients are most susceptible to the adverse outcomes of extended length of stay and discharge to a facility. Future research in this area will allow physicians to identify suitable candidates for outpatient shoulder arthroplasty, and we provide an outline for these criteria based on a critical review of the current literature. Because of the limited information regarding patient factors affecting length of stay and discharge disposition, additional high-level research is needed, possibly including randomized control trials, aimed at safely reducing length of stay and unfavorable discharge disposition in healthy surgical candidates.